HIGH PLAINS CROSSING — Colorado Facility Report

Inspections

Deficiencies

Actual Harm or Above

Occurrences

July 16, 2026

Last Inspection

S/S A/B/C Minimal potentialS/S D Potential for harm

The most recent inspection of HIGH PLAINS CROSSING on record is dated July 16, 2026. Across 20 published inspections, state surveyors cited 37 deficiencies, none of which reached the actual-harm level.

Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.

Provider Information

Status

Active

Facility Type

Assisted Living Residence (Licensed Only)

Administrator

Jacquay, Amy

Owner

GREELEY MEMORY CARE LLC

Phone

(970) 449-7199

Payor Source

Private Pay

City

GREELEY

ZIP

80634

Inspections & Citations

20 inspections · 37 deficiencies

7/16/2026Revisit: Licensure Complaint · ID TE8712No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 7/16/26 for all previous deficiencies cited on 5/7/26. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

5/7/2026Licensure (Re-licensure) · ID 4TMJ11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

An administrative relicensure survey was completed on 5/7/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

5/6/2026Licensure Complaint · ID TE87111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO41368, was completed on 5/7/26. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

A licensure complaint, prompted by #CO41368, was completed on 5/7/26. One deficiency was cited. Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting two current and one former of six sample residents whose medications were reviewed (#3, #4, and #5). Findings include:Resident #3 was admitted to the residence on 2/28/26, with diagnoses including unspecified dementia (severe), Parkinson ' s disease, and essential hypertension. A signed practitioner's order dated 4/30/26, directed the residence to administer 0.5 tablet of oxycodone HCI 5 mg twice daily for knee pain. A medication error report indicated an error for Resident #3 reported on 5/5/26. An Incident Report dated 5/5/26 indicated on 5/4/26, the medication oxycodone was signed on the Medication Administration Record (MAR) as administered. The narcotic bubble packet showed the tablet was still in the bubble for that dosage time. The medication was not administered to Resident #3. However, record review of Resident #3 ' s May, 2026 MAR, reflected that the medication had been administered during the morning of 5/4/26, contrary to what the incident report noted. On 5/7/26 at 10:46 a.m., Staff #3 stated they were alerted to the error by Staff #2 because the tablet was in the bubble the previous day. Staff #3 stated the bubble pack lacked any staff initials, which was part of the administration process. Staff #3 stated that Staff #4 was on shift during the medication error on 5/4/25, however, Staff #4 did not recall that medication administration error when asked about the event, but Staff #4 took responsibility for the error. Staff #3 reported that Staff #4 went through an in-service and was shadowed during their next shift. On 5/7/26 at 2:24 p.m., Staff #4 stated they did not remember the medication administration on 5/4/26 in general. They thought the medication had popped out of the bubble pack, but it must not have come out of the bubble pack. Staff #4 stated they did not know about it until their next shift on 5/7/26. Staff #4 stated they were taken aside and told about the error, and then went through retraining. There was similar deficient practice found for Residents #4 and #5.

Plan of correction · submitted by the facility

6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Orders 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. This Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. Description of how the licensee will correct each identified deficiency. Residents 3,4,5 were monitored at the time of the error for any adverse reactions and none were noted. Staff #4 was counseled and removed from passing further medications. Staff # is no longer employed at this community. Verification audit completed on controlled substances to ensure count matches on hand medications initiated and continues weekly X60 days. Then monthly thereafter. Reviewed policy on Medication AdministrationStaff who manage medications for residents were educated on medication administration, how the error occurred and corrective action taken to prevent recurrence as well as expectation of immediately reporting any discrepancies. Re-competency each QMAP by compliance date. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. Exactly how and what will be reviewed as part of the monitoring. A 100% MAR to Cart audit will be performed weekly x 4 weeks, then monthly x 2 months to ensure compliance. Verification audit completed on controlled substances to ensure count matches on hand medications, weekly x 4 weeks, then monthly x 2 months to ensure compliance. Medication exception audit will be performed weekly x 4 then monthly x 2 months to ensure compliance. The sample, representative of the facility census, included in the monitoring. 100% of medication orders will be reviewed for accuracy. How often the monitoring will occur. The Health Services Director or designee will perform audits weekly x 4 weeks, then monthly x 2 months to ensure compliance. How the monitoring will be documented. The MAR to Cart audit will be documented via a checklist of all orders. Controlled Substance audit weekly x 4, then monthly x 2Medication Exception Audit weekly x 4, then monthly x 2How the monitoring will be included in the QAPI processThe Executive Director or designee will report findings quarterly to the QMP Committee for at least 3 months until substantial compliance is maintained. Date of compliance06/12/2026

10/8/2025Revisit: Licensure Complaint · ID WWZF12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 10/8/25 for all previous deficiencies cited on 6/5/25. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

6/4/2025Licensure Complaint · ID WWZF113 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint survey, prompted by #CO40163, was completed on 6/5/25. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0734Stf Req-First Aid 1 Stf Onsite CPRS/S B▼

Findings

Based on observation, record review and interview, the residence failed to ensure there was at least one staff member onsite at all times with current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization and shall include a skills assessment observed and evaluated by an instructor affecting seven current residents who may require obstructed airway techniques. Findings include:The May 2025 schedule read in part that Staff #4 and #5 worked from 2 p.m. to 10 p.m. at the residence on 5/1, 5/7, 5/14, 5/21, 5/27 and 5/28 with no other staff scheduled during that shift. Additionally, Staff #4 worked the same shift alone on 5/5 and Staff #5 on 5/2, 5/3, 5/9, and 5/10. The residence provided a list of staff that were currently CPR certified by a nationally recognized organization. The residence did not provide CPR certifications for Staff #4 and #5. On 5/4/25 at approximately 12:35 p.m., the area director acknowledged the shifts and times lacking someone with a CPR certification.

Plan of correction · submitted by the facility

S 0734 Staffing Requirements-First Aid, Obstructed Airway Technique and Cardiopulmonary ResuscitationThis Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. Description of how the licensee will correct each identified deficiency. During the survey on 6/4/25, a 100% audit of all associates was completed to identify current CPR and First Aid trained associates. During the survey, the schedule for the remainder of June was adjusted to ensure there was an associate on every shift with current CPR and First Aid certification, this was presented to the surveyor on 6/4/25. Area Director of Clinical Services will educate Executive Director, Health Services Director on CDPHE Staffing Requirements regulation. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. Exactly how and what will be reviewed as part of the monitoring. The Executive Director or designee will review the schedule weekly x 4 weeks to identify any gaps in the upcoming schedule where there is not an associate trained in First Aid and CPR in the community. Any shifts identified to not be in regulatory compliance, will be remedied prior to that shift and that will be reflected on the staffing schedule. The sample, representative of the facility census, included in the monitoring. The following week’s schedule will be reviewed. How often the monitoring will occur. The Executive Director or designee will review the schedule for the following week, weekly x 4 weeks then will review the monthly schedule prior to the next month, monthly x the next 2 months. How the monitoring will be documented. Executive Director or designee will document weekly and monthly schedule reviews on an audit tool. How the monitoring will be included in the QAPI processThe Executive Director or designee will report findings quarterly to the QMP Committee for at least 3 months until substantial compliance is maintained. Date of compliance: 08/02/2025

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S C▼

Findings

Based on interview and record review the residence failed to comply with practitioner's orders, affecting two of three sample residents for whom medications were reviewed (#1, #2). (Cross-Reference T1600)Specifically, a practitioner's order for Resident #1, dated 5/2/25, directed the residence to administer morphine sulfate solution 100mg/5ml (20 mg/ml) orally by mouth every six hours. The May 2025 medication administration record (MAR) read Staff #1 did not administer medication on 5/5/25 at 8:00 a.m., and 12:00 p.m., and on 5/6/25 at 8:00 a.m. as the MAR did not match the order. Therefore, the resident went without three doses of morphine and subsequently experienced pain. Findings include:1. Resident #1 was admitted to the residence on 8/12/20 a diagnosis including Alzheimer's disease. MorphineA written practitioner's order, dated 5/2/25, directed the residence to administer morphine 100 mg/5mL every six hours. However, the May 2025 MAR read the morphine was not administered on 5/5 and 5/6. Additionally, it read that the residence refused to administer the medication on 5/5 and 5/6 until the MAR was corrected to reflect the written practitioner's order. An external hospice provider (EHP) note, dated 5/6/25, read in part Staff #6 telephoned the EHP nurse and reported Resident #1 had not received her medication every six hours as scheduled and "is in pain and needs her pain medication." Additionally, the residence was unable to administer medication as the MAR did not match the practitioner's order. The responding EHP hospice nurse noted that upon their arrival Resident #1 was frowning and was tense and appeared to be in pain. LorazepamA written practitioner's order, dated 5/6/25, directed the residence to administer lorazepam 2mg/mL oral concentrate 0.25 milliliters every 12 hours. The residence failed to administer the medication at 8:00 a.m. on 5/18/25 but documented on the resident's medication administration (MAR) that it was administered. An EHP note, dated 5/18/25, read in part that the residence's health services director (HSD) reported a medication error that occurred at 9 a.m. The HSD reported that Resident #1 was "given two syringes of 0.25 mL morphine instead of one morphine syringe of 0.25 mL and one lorazepam syringe of 0.25 mL."2. InterviewsOn 6/4/25 at approximately 8:20 a.m., the HSD acknowledged that the residence had errors with medications and issues with medication management. At 9:02 a.m., the HSD stated that she incorrectly administered an incorrect dose of morphine but had instead administered twice the prescribed dose. She added that she failed to administer Resident #1 the prescribed lorazepam at 8:00 a.m. on 5/18/25 but documented on the resident's MAR that she administered the medication. On 6/4/25 at approximately 2:23 p.m., Staff #1 stated that she refused to administer morphine to Resident #1 as the MAR was incorrect and did not reflect the correct schedule to administer the medication. 3. Similar deficient practice was found for Resident #2.

Plan of correction · submitted by the facility

(Cross-Reference T1600)6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Orders 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administerThis Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. Description of how the licensee will correct each identified deficiency. Resident #1 no longer resides in the community and therefore any irregularities are unable to be corrected for resident #1. No details were provided regarding resident #2 therefore corrective action regarding resident #2 was not able to occur, however orders for resident #2 were reviewed and no current concerns were identified. In collaboration with Community’s pharmacy and EHR providers, Community systematically identified how the error for resident #1 occurred. This isolated error in the timing of doses was due to an unknown problem with the interface between the pharmacy’s computer system and the community’s electronic medical record. This function of the interface between the pharmacy system and the ALIS electronic medical record at the community has been disabled to prevent this from reoccurring. All orders are now manually reviewed to ensure the correct times are assigned. A 100% audit of all orders was completed, and no other issues were identified. Staff who manage medications for residents were educated on the error, how it occurred and corrective action taken to prevent recurrence as well as expectation of immediately reporting any discrepancies. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. Exactly how and what will be reviewed as part of the monitoring. A 100% MAR to Cart audit will be performed weekly x 4 weeks, then monthly x 2 months to ensure compliance. The sample, representative of the facility census, included in the monitoring. 100% of medication orders will be reviewed for accuracy. How often the monitoring will occur. The Health Services Director or designee will perform audit weekly times 4 weeks and then monthly for July and August. How the monitoring will be documented. The MAR to Cart audit will be documented via a checklist of all orders. How the monitoring will be included in the QAPI processThe Executive Director or designee will report findings quarterly to the QMP Committee for at least 3 months until substantial compliance is maintained. Date of compliance08/02/2025

1600Med/Med Adm-Rcrd Kpng MARS/S A▼

Findings

Based on record review and interview, the residence failed to ensure that each medication administration record (MAR) included the time of administration for each medication and failed to ensure that each qualified medication administration person (QMAP) accurately documented each medication administration event at the time the event was completed for each resident, affecting one of three sample residents (#1). (Cross-reference T1568)Resident #1 was admitted to the residence on 8/12/20 a diagnosis including Alzheimer's disease. A written practitioner's order, dated 5/2/25, directed the residence to administer morphine 100 mg/5mL every six hours. However, the May 2025 MAR directed the residence to administer the medication at 3:00 a.m., 8:00 a.m., 12:00 p.m., 1:30 p.m., 5:00 p.m., 7:30 p.m., and 9:00 p.m., which was not every six hours as the order directed. The May 2025 MAR exceptions read:On 5/3, at 5:17 p.m., the morphine 100 mg/5 ml read that the order read that the residence was to administer the medication every six hours; however, the MAR did not reflect that order. On 5/5, at 10:00 a.m., the morphine 100 mg/5 ml read that the order read that the residence was to administer the medication every six hours; however, the MAR did not reflect that order. The QMAP refused to administer the medication until the medication error was corrected. On 5/5, at 12:32 p.m., the morphine 100 mg/5 ml read that the order read that the residence was to administer the medication every six hours; however, the MAR did not reflect that order. The QMAP refused to administer the medication. The QMAP refused to administer the medication until the medication error was corrected. On 5/5, at 7:51 p.m., the MAR does not match the morphine order. On 5/6, at 11:13 a.m., the morphine 100 mg/5 ml read that the order read that the residence was to administer the medication every six hours; however, the MAR did not reflect that order. The QMAP refused to administer the medication. The QMAP refused to administer the medication until the medication error was corrected. A written practitioner's order, dated 5/6/25, directed the residence to administer lorazepam 2mg/mL oral concentrate 0.25 milliliters every 12 hours. The residence failed to administer the medication at 8:00 a.m. on 5/18/25 but documented on the resident's medication administration (MAR) that it was administered. An EHP note, dated 5/18/25, read in part that the residence's health services director (HSD) reported a medication error that occurred at 9 a.m. The HSD reported that Resident #1 was "given two syringes of 0.25 mL morphine instead of one morphine syringe of 0.25 mL and one lorazepam syringe of 0.25 mL."On 6/4/25 9:02 a.m., the HSD stated that she failed to administer Resident #1 the prescribed lorazepam at 8:00 a.m. on 5/18/25 but documented on the resident's MAR that she administered the medication.

Plan of correction · submitted by the facility

(Cross-reference T1568)6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Record Keeping 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication. (B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications. This Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. Description of how the licensee will correct each identified deficiency. Resident #1 no longer resides in the community and therefore any irregularities are unable to be corrected for resident #1. In collaboration with Community’s pharmacy and EHR providers, Community systematically identified how the error for resident #1 occurred. This isolated error in the timing of doses was due to an unknown problem with the interface between the pharmacy’s computer system and the community’s electronic medical record. This function of the interface between the pharmacy system and the ALIS electronic medical record at the community has been disabled to prevent this from reoccurring. All orders are now manually reviewed to ensure the correct times are assigned. A 100% audit of all orders was completed, and no other issues were identified. Staff who manage medications for residents were educated on the error, how it occurred and corrective action taken to prevent recurrence as well as expectation of immediately reporting any discrepancies. Executive Director provided education to HSD regarding ensuring that medication administration in the MAR must be accurate even though HSD did clearly document the medication error in the observation notes and incident report. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. Exactly how and what will be reviewed as part of the monitoring. A 100% MAR to Cart audit will be performed weekly x 4 weeks, then monthly x 2 months to ensure compliance. Review of medication error documentation will be completed every weekday as a part of the clinical systems review. The sample, representative of the facility census, included in the monitoring. 100% of medication orders will be reviewed for accuracy. How often the monitoring will occur. The Health Services Director or designee will perform audit weekly times 4 weeks and then monthly for July and August. Medication errors will be reviewed every weekday for the next 3 months. How the monitoring will be documented. The MAR to Cart audit will be documented via a checklist of all orders. Medication error reviews will be documented on the daily clinical form. How the monitoring will be included in the QAPI processThe Executive Director or designee will report findings quarterly to the QMP Committee for at least 3 months until substantial compliance is maintained. Date of compliance: 08/02/2025

12/3/2024Revisit: Licensure Complaint · ID I9ED12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 1/21/25 for previous deficiencies cited on 10/8/24. The agency is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Plan of correction

The state did not require a plan of correction for this citation.

10/8/2024Licensure Complaint · ID I9ED115 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO37591, #CO36972 and #CO37563, was completed on 10/8/24. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1526Med/Med Adm-Gen Rq PRNS/S A▼

Findings

Based on interview and record review, the residence failed to ensure that qualified medication administration persons (QMAP) did not administer as-needed medications (PRNs) to residents who were not capable of requesting the medication affecting one sample resident (#3). Findings include:Resident #3 was admitted to the secure environment on 7/27/23 with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, and hypertensive heart disease with heart failure. A written practitioner's order, dated 9/20/24, directed the residence to administer Seroquel 25 mg every 12 hours PRN. However, the September through October 2024 medication administration records (MARS) read the PRN medication was administered on 9/29, 10/2, 10/4, and 10/6/24 by Staff #2, #5, and #6. A written practitioner's order, dated 9/20/24, directed the residence to administer acetaminophen 325 mg two tablets every six hours PRN. However, the September through October 2024 MARs read the PRN medication was administered on 9/28 for a partial dose, 10/1, 10/3, and 10/4/24 by Staff #2, #5, and #8. On 10/8/24 at approximately 8:00 a.m., Staff #5 stated Resident #3 was administered PRN medications. On 10/8/24 at 1:16 p.m., the administrator stated Resident #3 was not capable of requesting PRN medication. She stated she was aware QMAPs could not administer PRN medication to residents who could not request it; however, she stated that she thought they could administer the medication if a nurse or external hospice directed them to administer the medication. On 10/8/24 at 3:44 p.m., the health services director stated he was aware QMAPs could not administer PRN medications to residents who could not request them; However, he stated he thought it was okay if external hospice directed the QMAP to administer the PRN medication.

Plan of correction · submitted by the facility

PRN orders were discontinued or amended to state that only a nurse may administer. If staff are administering the PRNs, disciplinary actions will be executed since the QMAPs should not be administering PRNs. All the Hospice companies and Bloom will be educated about the use of PRNs in our community. Companies need to be aware that the orders need to be addressed that only Hospice may administer and to contact Hospice is particular symptoms are present and also to educate staff on what the symptoms are. The current and future residents have the potential to be impacted. All staff have been educated on the facility policy related to medication administration, in particular that QMAPs are not allowed to administer PRN medication. All staff have been educated on what to do if a PRN order is received from a medical provider. PRN orders are not to be sent to the pharmacy to be filled. The medical provider will be notified and it will be explained that the provider that the facility wis not able to administer a PRN mediation or treatment and an appropriate will be notified. Hospice providers may have PRN orders for their nurses to utilize. These orders will not be entered into the facility Medication Administration Record. The hospice nurse may administer medications to a resident and document administration of those medications in the hospice chart and provide a copy of the documentation for the facility records. All orders will be processed using the facility three-check process, being checked by three staff prior to being implemented and receive proper clarification. The Three Check Process for Orders and Paperwork will be followed and audited by the Administrator and Nurse or RCC. This audit will ensure that all orders are worded correctly and corrected immediately once it is reviewed.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interview the residence failed to comply with authorized practitioner ' s orders affecting two of three sample residents (#2, #3). (Cross-reference S1604)Findings include 1. The residence policy and procedure titled Medication Administration, dated May 2024, read in part: Medications were administered to residents in compliance with all applicable federal and state laws. The medication order and medication label were carefully compared and the six rights of medication administration were followed for each resident. 2. Resident #2 was admitted to the residence on 11/30/23, with diagnoses including hypertension, heart disease, dementia, unspecified pain in joint, heart failure, cardiomegaly, chronic kidney disease, Alzheimer ' s disease, and vascular dementiaa. AcetaminophenA written practitioner ' s order, dated 8/26/24, directed the residence to administer acetaminophen 500 mg two tablets once daily. However, the September and October 2024 medication administration records (MARs) for Resident #2 revealed the medication had never been transcribed and was not administered from 9/1-10/7/24.c. IbuprofenA written practitioner ' s order, dated 8/26/24, directed the residence to administer ibuprofen 200 mg. However, the September and October 2024 MARs for Resident #2 revealed the medication had never been transcribed and was not administered from 9/1-10/7/24.d. Centrum Silver (Multiple Vitamins- Minerals)A written practitioner ' s order, dated 8/26/24, directed the residence to administer one tablet orally daily. However, the September and October 2024 MARs for Resident #2 revealed the medication had never been transcribed and was not administered from 9/1-10/7/24. On 10/8/24 at approximately 2:00 p.m., the health service director confirmed the residence had left medications off the MARs for Resident #2 and therefore the medications were not administered. On 10/8/24 at approximately 5:30 p.m., the administrator stated that she was not aware medications were not being administered to Resident #2.

Plan of correction · submitted by the facility

The residents addressed with this tag were corrected day of the survey. Resident 3 was fixed the day of the survey by clarification from Hospice who was in the community that day. Resident 4 was clarified by the provider and discontinued same day of survey. Daily the Nurse will run a Order Listing Report to make sure that we have all orders that are matching the MAR. If not the Nurse or RCC will contact provider to either D/C or clarify. All QMAPs will be reeducated on the policy and procedure for processing orders and visit notes from medical providers. In addition, QMAPs must process orders the day they are received from the medical provider. Visit notes from medical providers that contain a list of medications must be reconciled with the current orders in the facility recorders. Any discrepancies will be clarified with the medical provider. If the QMAP is unable to process an order for any reason, the RCC and/or Health Services Director must be notified, as well as the medical provider and POA.All orders must remain in the three-check bins until all steps in the three-check process has been completed. If the RCC or Health Services Director needs a copy in order to further work on the order, a copy my be made, the word “Copy” written on their copy, and a sticky note placed on the original indicating they are working on the order. QMAPs on the evening shift will verify that all medications are received in the medication delivery for all orders faxed that day to the pharmacy. The pharmacy will be contacted related to medications not received, and orders will be faxed. Documentation will be made in the medical record regarding all actions taken related to notification of the medical provider and/or pharmacy to obtain clarification of an order or any actions to receive medications. All QMAPs will check “Orders Pending Confirmation” in PCC each shift to ensure no outstanding orders waiting to be processed. The RCC and Nurse will also check “Orders Pending Confirmation” daily. All orders will remain in the three-check bins until all steps in the three-check process have been completed and the order is fully implemented. The nurse and/or RCC will check the order bin throughout the dy to monitor the status of pending orders and will help ensure prompt processing of all orders. We will be following the same protocol as in Tag 1604, which is to audit weekly and then audit quarterly. The team will be sending the orders to the providers to verify signatures for all medications.

1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor on a quarterly basis, audited the accuracy and completeness of the medication administration records, and controlled substance list, affecting 28 current residents. Findings include"1. Record reviewThe residence controlled substances audit tool a controlled medication audit was completed on 5/30/24 by the residential care coordinator (RCC), the health service director (HSD), and the administrator. The document read a controlled medication count had been conducted and no errors were found signed by the RCC, HSD, and administrator. This audit did not include the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. The undated north and south audit tool read in part: Audits were completed on the north and south carts, the items audited included; the resident's name, medications in the cart, discrepancies, labeled over-the-counter medications, dated eye and nose drops, and sprays, medications reordered. This audit did not include the accuracy and completeness of the medication administration records, controlled substance lists, medication error reports, and medication disposal records or that irregularities were investigated and resolved and there was no documented evidence of who completed the audit. 2. InterviewOn 10/8/24 at approximately 5:30 p.m., the administrator stated that audits were completed by looking for discrepancies between the medication cart and the medication administration record, she acknowledged that the signed practitioner ' s orders were what the residence should have used to find discrepancies between the MAR and the medication cart. On 10/8/24 at approximately 5:15 p.m., the RCC stated that the last quarterly audit completed by the RCC, HSD, and administrator was on 5/30/24. On 10/8/24 at approximately 5:20 p.m., the HSD stated that he completed weekly medication cart audits to ensure all medications were in the cart, that there were no discrepancies, that over-the-counter medications were labeled, that eye and nose drops and sprays were dated and not expired and that needed medications were reordered.

Plan of correction · submitted by the facility

The administrator and the QMAP supervisor shall on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports and medication disposal records. The controlled substances audit tools will be used for both quarterly and weekly audits. The next quarterly audit will be on November 1, by the RCC, Health Services Director and the Administrator. Weekly audits will be completed by the RCC and Health Services Director to ensure that errors are addressed and corrected before the quarterly audits are completed. This affects all residents in the community and potential for future residents. To make sure we are complying with this tag, the Nurse and RCC will be conducting a weekly audit using the Medication Error Audit Tool. This will be reviewed to illuminate any errors prior to the quarterly audit. The quarterly audit will be monitored by using the Medication Administration Records, Medication Error Forms and the Medication Disposal Records. The documentation will be collected from the weekly audits and discussed in the quarterly audits. Any discrepancies will be reviewed and investigated and send off to the Regional clinical team for Windsong.

1634Med/Med Adm-Med Strge Dbl LckdS/S B▼

Findings

Based on observation, record review and interview the residence failed to ensure that two qualified individuals jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred; affecting seven residents prescribed narcotics. (Cross-reference S1604)Findings include:On 10/8/24 at approximately 7:45 a.m., the north medication cart revealed the controlled substance count for 10/8/24 had not been signed by two qualified individuals going "off duty" and "on duty". At approximately 7:50 a.m., Staff #4 signed the "on duty" section for that date. A review of the controlled substance count sheets revealed the following;9/18/24 - no signature for on-duty9/20/24 - no signature for off-duty9/21/24 - no signature for off-duty9/22/24 - no signature for off-duty9/23/34 - no signature for off-duty9/24/24 - no signature for off or on-duty9/25/24 - no signature for off-duty9/26/24 - no signature for off-duty9/27/24 - no signature for off-duty9/28/24 - no signature for off or on-duty9/29/24 - no signature for off or on-duty9/30/24 - no signature for off or on-duty10/1/24 - no signature for on or off-duty10/4/24 - no signature for on-duty10/7/24 - no signature for off-dutyOn 10/8/24 at approximately 5:30 p.m., the administrator stated she was not aware the morning shift had not counted the controlled substances when they changed shifts

Plan of correction · submitted by the facility

According to the two individuals who complete a controlled substance count, they are required to sign the documentation sheet providing that all counts are completed and accounted for. If there is a discrepancy or is not signed, the Resident Care Coordinator and the Nurse need to be made aware before the QMAPs can leave the shift. The Nurse or RCC will come to the community to identify the error. The administrator also needs to be notified right away of the situation. The administrator will document and keep a record of the event. This will help also when doing our QAPI discussion monthly. The staff that were involved with the signatures not being documented were reeducated and disciplinary actions were completed. The tag was corrected with the staff that were listed with disciplinary action as all QMAPs were reeducated about the procedure. The controlled substance count sheets should be counted on each shift being relieved and coming on shift. The RCC will monitor and ask for follow-up if the counts are off or if there are any holes in the documentation. This needs to be identified and notified immediately when an error is noticed. The policy and procedures for Audits by Administrator and QMAP are followed. The documentation that is needed is the daily narcotic medication count sheet. This is also provided as a sample sheet only. Starting November 4, the QMAPS will make sure the count sheets are completed, and no discrepancies are known. If so, the RCC will be notified immediately. All the audit tools will be brought to the monthly QAPI meeting to make sure there are no discrepancies.

3078Sec Env-Stff Tr 6 hr-TpcsS/S B▼

Findings

Based on record review and interview the residence failed to provide each staff member a minimum of six hours of general training and education on providing care and services for residents with dementia/cognitive impairment for one staff (#1) affecting 28 current residents. Findings include 1. Record reviewThe personnel files for Staff #1 revealed no evidence that they had completed a minimum of six hours of general training and education on providing care and services for residents with dementia/cognitive impairment. The residence's new employee orientation checklist under the title additional documentation, revealed no documented dementia training for Staff #1. Personnel files and the staff schedule for August through October 2024 read Staff #1 was hired on 7/3/24 and worked in the secure environment without the required dementia training for 12 shifts. 2. InterviewOn 10/8/24 at approximately 2:45 p.m., the administrator said the residence orientation training and process consisted of four days of in-class training with a required demonstrated skills checklist completed before they could move on to shadow another staff which could last for as many days as they need before working independently. The administrator acknowledged that she was not aware that staff needed to have a minimum of six hours of general training and education on providing care and services for residents with dementia/cognitive impairment within 60 days.

Plan of correction · submitted by the facility

After reviewing our orientation process for new hires and current staff, we have given the completion date of November 30 to complete the minimum training requirements for the six hours of dementia care training to be in compliance. When an audit is conducted December 1, if a staff member is not in compliance they will be removed from the schedule until completed. In our revised orientation packet, we have included a session in which all new hires will receive Relias log in information to complete the required six hours of dementia care training to be completed in the first 60 days of employment. Any new hires that start in November, will start the first 60 day allowance to complete the requirement. All other staff have until, November 30 to complete the required trainings for dementia. As part of our QAPI meetings we will run a report to audit all of the completions of the six hours of required dementia care to make sure all staff are in compliance. The reports will be run and brought to QAPI for discussion. Starting November 4, we will make sure that all of the current staff have availability to Relias for their trainings. All current employees will be complying as of November 31 and on December 1 an audit will be conducted. QAPI will be when we discuss who needs to be encouraged more to complete the required trainings.

9999Final ObservationsSurveyor note▼

Findings

Plan of correction

The state did not require a plan of correction for this citation.

9/13/2024Revisit: Licensure Complaint · ID KT2Q13No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 9/13/24 for all previous deficiencies cited on 6/19/24. The facility is in compliance with all deficiencies that were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Plan of correction

The state did not require a plan of correction for this citation.

9/13/2024Revisit: Licensure and Licensure Complaint (Combined) · ID ZTHT12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 9/13/24 for all previous deficiencies cited on 6/19/24. The facility is in compliance with all deficiencies that were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Plan of correction

The state did not require a plan of correction for this citation.

9/13/2024Revisit: Licensure Complaint · ID FENB13No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 9/13/24 for all previous deficiencies cited on 6/19/24. The facility is in compliance with all deficiencies that were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9/13/2024Revisit: Licensure Complaint · ID 6SVJ14No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 9/13/24 for all previous deficiencies cited on 6/19/24. The facility is in compliance with all deficiencies that were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Plan of correction

The state did not require a plan of correction for this citation.

6/18/2024Revisit: Licensure Complaint · ID 6SVJ131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 6/19/24 for all previous deficiencies cited on 9/14/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 11/15/23.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting three of four (#5, #17, #14) sample residents. This deficiency was cited previously during a state licensure survey 9/14/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #5 was admitted to the residence on 9/12/22 with diagnoses including dementia.a. AcetaminophenA written practitioner's order, dated 5/13/24, directed the residence to administer acetaminophen 650 mg extended release one tab BID (two times a day). However, the May 2024 and June 2024 medication administration records (MARs) read that the residence failed to administer the medication in the morning on 5/18/24-5/20/24, 5/22/24-5/27/24, 6/11/24, and in the evening on 5/17/24-5/26/24, for a total of 20 missed doses due to the medication being unavailable. The MAR documented the medication as arthritis pain relief. However, the resident care coordinator said it was acetaminophen.b. Anti-diarrhealA written practitioner's order, dated 8/1/24, directed the residence to administer anti-diarrheal 2.5 mg one tab twice daily. However, the May 2024 and June 2024 MAR read that the residence failed to administer the medication on both doses on 5/5/24,5/23/24,5/25/24-5/30/24, 6/1/24,6/2/24,6/4/24-6/8/24 and the evening dose on 5/24/24 and 6/3/24, for a total of 32 missed doses due to the medication being unavailable.c. Citalopram HydrobromideA written practitioner's order, dated 1/18/23, directed the residence to administer citalopram hydrobromide 40 mg tablet once daily. However, the May 2024 and June 2024 MAR read that the residence failed to administer the medication on 5/5/24, 5/7/24-5/10/24, 5/27/24-5/30/24, 6/1/24, and 6/4/24-6/13/24 for a total of 20 missed doses because the medication was unavailable.d. RisperidoneA written practitioner's order, dated 10/13/23, directed the residence to administer risperidone 0.25 mg tablets BID. However, the May 2024 MAR read that the residence failed to administer both doses 5/5/24, 5/22/24, 5/23/24, 5/25/26/24, the morning dose on 5/27/24 and the evening dose on 5/24/24, for a total of 11 missed doses due to the medication being unavailable.e. SpironolactoneA written practitioner's order, dated 1/18/23, directed the residence to administer spironolactone 25 mg tablet every morning related to heart failure. However, the May 2024 MAR read that the residence failed to administer the medication on 5/5/24, 5/7/24- 5/10/24, 5/26/24 and 5/27/24 for a total of eight missed doses because the medication was unavailable.f. TramadolA written practitioner's order, dated 1/18/23, directed the residence to administer tramadol 50 mg tablet and give 0.5 tablet twice daily. However, the May 2024 and June 2024 MAR read that the residence failed to administer the medication of both doses on 6/10/24-6/13/24 and the morning dose on 5/7/24, for a total of seven missed doses due to the medication being unavailableOn 6/18/24 at 7:50 a.m., Staff #13 said the residence did not have a process to ensure medications did not run out. She said she notified the pharmacy if she noticed the resident had seven days left of medication. Further, Staff #13 stated if a medication were unavailable, she documented it in the MAR. On 6/19/24, at approximately 10 a.m., the administrator said qualified medication administration person (QMAP) should follow the practitioner's orders. She stated QMAPs contacted the nurse or pharmacy to get more medications if a medication was out. The administrator said she understood the residence's responsibility was to ensure the residents had all their medications in stock. 2. Additionally, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration for Resident #17 and Resident #14.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Plan of correction

The state did not require a plan of correction for this citation.

6/18/2024Revisit: Licensure Complaint · ID FENB121 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 6/19/24 for the previous deficiency cited on 10/24/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 11/15/23.

Plan of correction

The state did not require a plan of correction for this citation.

1320Res Rghts Rts/Rspn-Civ/Rel-Dig-RspctS/S B▼

Findings

Based on record review and interview the residence failed to ensure residents were treated with dignity and respect, affecting three of five sample residents (#14, #16, #17). (Cross reference S410, S648, S1410)This deficiency was cited previously during a state licensure survey 10/24/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's Resident Right policy, dated November 2017, read in part: "residents ... shall have the following rights: the right to be treated with respect and dignity."2. Record ReviewResident #17 was admitted to the residence on 9/21/20 with a diagnosis of vascular dementia. The residence's care plan for Resident #17, dated 4/29/24 read the resident was incontinent of both bowel and bladder and required staff to check the resident for incontinence every two hours and perform perineal care when soiled which included changing the resident's soiled brief and applying barrier cream. The residence's investigation of abuse, read on 6/11/24 Former Staff #19 stated he checked a resident for soiledness by putting his hand inside the brief to feel if it was wet if the resident was lying on their side, or putting two fingers inside the brief with the fingers curled up facing outward but not toward the resident and squeezing it for wetness. A letter of termination dated 6/12/24 read Former Staff #19 was terminated for violating resident rights. 3. InterviewsOn 6/18/24 at 12:07 p.m., Former Staff #19 stated he was hired as a qualified medication administration person (QMAP) and had no experience with providing perineal care on incontinent residents and had not received training on incontinence care prior to working independently. He stated he had observed other staff members check a resident for incontinence by squeezing the inside of a resident's incontinence brief and that was how he would check to see if a resident was soiled. On 6/18/24 at 3:35 p.m., Staff #17 stated she had observed Former Staff #19 put his hand in a resident's brief to check for it being soiled, but was unsure which resident it was. Staff #17 stated she had never observed Former Staff #19 touching a resident inappropriately; however, stated staff were trained to check a resident from outside the brief since a line would show up a different color on the outside when soiled. Staff #17 stated she felt Former Staff #19 checking a resident from inside the brief was "disrespectful" to the resident and "a violation of their rights."On 6/19/24 at 7:29 a.m., Resident #17's legal representative stated she was "disturbed" to hear how Former Staff #19 checked Resident #17 for soiledness, and stated although it was uncertain that what had occurred was sexual abuse, she felt it was a violation of Resident #17's rights. On 6/19/24 at approximately 10:20 a.m., the administrator stated staff were trained to check a resident for incontinence by observing the colored line change on the outside of the brief, or if unable to tell by squeezing the outside of the brief. The administrator stated she was unsure why Former Staff #19 had not been trained on incontinence care, and stated Resident #17 should not have been checked for incontinence from inside the brief. She further stated she expected residents to be treated with dignity and respect and stated by checking a resident for incontinence from inside the brief, Former Staff #19 had not respected the resident's rights. 4. There was similar deficient practice for Residents #14 and #16.

Plan of correction · submitted by the facility

(Cross reference S410, S648, S1410)The below plan of correction has been implemented to correct the deficient practice for the affected residents. All current residents and future residents who wear pendants have the potential to be affected, as well as any resident in the facility who may pull an emergency cord, call light cord, or press on a door to set off an alarm. All current residents and future residents who wear pendants have the potential to be affected, as well as any resident in the facility who may pull an emergency cord, call light cord, or press on a door to set off an alarm. All current staff will be reeducated on the following:The expectation that call lights and emergency lights are to be answered as soon as possible by the first available staff person, and cleared within 15 minutes. At the start of report, prior to getting report, the QMAP will ensure that all staff on duty have a pager and a walkie-talkie. A new “QMAP Shift Duty Checklist” has been developed and this is the first item listed. The QMAP will sign the checklist each shift to indicate this step was completed. When a pager indicates a call light/pendant/emergency light/door alarm is sounding, the QMAP is to use the walkie-talkie to determine who is available to respond right away; The first available staff member is to respond. The QMAP is responsible for ensuring the light is cleared. If it is a pendant that was pushed, the QMAP must take the pendant clearing device to the resident to clear the pendant. The QMAP is responsible for confirming the light was clearing by going to the panel in the health services office and viewing the screen. This is to be done within 10 minutes of the light going off. If the call light was answered within 10 minutes and the resident was cared for, but there were technical issues in being able to clear the pendant or light, the QMAP is to write a progress note in the resident’s record stating the time the call light went off, the time the resident was cared for, and the reason the light was not able to be cleared. Maintenance is to be notified of any equipment issues that need to be addressed. Information will be incorporated into new employee orientation for all future staff. Each business day, the call light report log will be reviewed for all call lights longer than 15 minutes. Progress notes will be reviewed to determine if care was provided and the light was unable to be cleared. An investigation will be conducted for any light longer than 15 minutes with no progress note indicating the reason and follow-up action will be taken as indicated. Copies of each call light report, investigation, and follow-up action will be maintained by the administrator. The Regional Nurse Consultant will review the results of the audits and actions taken with the administrator or designee monthly. A summary of the call light reports, including trending, will be reported to the facility QAPI meeting on a monthly basis and further systemic action taken as indicated. Initial education was conducted on 7/9/24 with a majority of staff. The remainder of staff will be educated by 7/31/24. A completion date for remaining items: July 31, 2024Additional Information:Since our restart for the survey, we have reeducated and still pulling the audits daily. We have have not had any call lights to go over 15 minutes.

6/18/2024Revisit: Licensure Complaint · ID KT2Q122 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 6/19/24 for all previous deficiencies cited on 9/14/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 11/15/23.

Plan of correction

The state did not require a plan of correction for this citation.

1352Res Rghts Rts/Rspn-Choice/Invlv Cr/Svc-CommS/S B▼

Findings

Based on interviews and record review, the residence failed to ensure the residents received the cooperation of the residence to achieve the maximum degree of benefit, affecting four of four sample residents (#18-#21). This deficiency was cited previously during a state licensure survey 9/14/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #11 was admitted to the residence on 8/31/23. The May 2024 and June 2024 Response Time Report documented for Resident #11 read that she pressed her pendant nine times with wait times longer than 15 minutes, as follows:6/6/24 at 12:40 p.m. for 59 minutes6/7/24 at 1:37 p.m. for 33 minutes 6/10/24 at 1:37 p.m. for 57 minutes6/10/24 at 11:07 a.m. for 28 minutes6/11/24 at 12:21 a.m. for 33 minutes6/11/24 at 6:33 p.m. for 26 minutes6/11/24 at 7:58 p.m. for 33 minutes6/12/24 at 3:43 a.m. for 49 minutes 6/12/24 at 11:30 a.m. for 24 minutes 2. Resident #19 was admitted to the residence on 5/20/24The May 2024 and June 2024 Response Time Report documented for Resident #19 read that he pressed his pendant one time with wait times longer than 15 minutes, as follows:On 6/9/24 at 10:35 a.m. for 24 hours and 28 minutes. 3. Resident #20 was admitted to the residence on 11/30/23. The May 2024 and June 2024 Response Time Report documented for Resident #20 read that she pressed her pendant two times with wait times longer than 15 minutes, as follows:6/1/24 at 6:53 p.m. for 29 minutes6/4/24 at 7:24 p.m. for 45 minutes 4. Resident #18 was admitted to the residence on 10/15/21. The May 2024 and June 2024 Response Time Report documented for Resident #18 read that she pressed her pendant one1 time with wait times longer than 15 minutes, as follows:On 6/6/24 at 12:40 p.m. for 1 hour and 43 minutes 5. InterviewsOn 6/19/24 at 8:55 a.m., Staff #19 said the staff should answer the call pendant immediately within a few minutes. Staff #19 said answering quickly in case the resident had an emergency was important. Staff #19 said it was very difficult to answer call pendant timely because the residence was short staffed at times. On 6/19/24 at 8:59 a.m., the administrator stated resident pendant lights should be answered within 10 minutes.

Plan of correction · submitted by the facility

Former employee #19 was immediately suspended pending the investigation once the incident was reported to the administrator and terminated at the conclusion of the investigation. Former employee #19 no longer works at the facility and is not eligible for rehire, so current and future residents do not have the potential to be affected by this employee. Current and future residents have the potential to be affected by staff potentially performing incorrect incontinence care. All staff providing incontinence care will continue to be trained on proper incontinence care prior to caring for residents. The level of training will be commensurate with prior knowledge and experience. Of note, Former Employee #19 reported to the surveyor that he had no experience providing perineal care on incontinent residents and had not received training on incontinence care. The Regional Nurse Consultant performed the initial interview prior to hire with Former Employee #19 which lasted over an hour. Former Employee #19 described extensive care giving experiencing, including performing ADLs on elderly dementia care residents. In addition, Former Employee #19 spent multiple days shadowing experienced staff on the night shift, including while performing incontinence care of residents, prior to completing care on his own. An orientation checklist was completed as confirmed by the preceptor who trained him, however, unfortunately could not be located at the time of the survey. An orientation checklist will be completed for all new staff confirming completion of all new hire education prior to a new employee caring for residents on their own. The facility will ensure the orientation checklist is maintained in the employee file (cross reference the plan of correction for tag 0664). Staff will be trained to promptly report any concerns regarding the care provided by another staff member to the QMAP supervisor, nurse , and/or administrator (cross reference tag 1410). All current staff will be retrained on the facility policy, “Perineal Care“All current staff will be retrained on the proper procedure for checking a resident to determine if a brief is wet or soiled and needs to be changed. Proper procedure includes looking at the wetness indicator on the outside of the brief and/or squeezing the outside of the brief. If there is any doubt as to the degree of wetness or soilage of a brief, the brief shall be changed using proper technique per facility policy. At no time shall a staff member insert their fingers into a brief to determine if it is wet or soiled. This information will be incorporated into new employee orientation and added to the new employee orientation checklist. The RCC or designee will perform rounds to observe RAs performing checks on incontinent residents monthly. Observations shall include at least 8 resident observations each shift each month of a variety of staff and residents on all shifts, any new staff hired within the month, and any new incontinent residents admitted within the month. Initial education was conducted on 7/9/24 with a majority of staff. The remainder of staff will be educated by 7/31/24. A completion date for remaining items: July 31, 2024Additional Information:Since our restart for the survey, we have reeducated and still pulling the audits daily. We have have not had any call lights to go over 15 minutes. We have illuminated the issue for residents #18 - 21.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Plan of correction · submitted by the facility

Resident #17 no longer resides in the facility. Residents #5 and #14 were included in the audit conducted for all residents on 7/9/24 and all medications were available to be administered. All current and future residents have the potential to be impacted. An audit was conducted on 7/9/24 and all residents had all medications available to be administered. An investigation was conducted on 7/1/24-7/2/24 by the Regional Nurse Consultant and Resident Care Coordinator to determine the root causes of why medications may not be available. Systems were created to improve the availability of medications and staff will be educated to those systems, to include:Medications on cycle fill but a pill had to be wasted for various reason (medication contaminated and a new medication dispensed, resident spit out and another medication dispensed, etc.) and a replacement medication was not ordered, so medications were short at the end of the cycle fill. A new process was implemented for a replacement medication to be ordered at the time an extra medication is dispensed. A “Pharmacy Communication: Replacement Medication Request“ will be faxed to the pharmacy when a replacement medication is needed. The form will be placed in a pink folder in the top bin of the triple check bins; The forms will be compared with medications delivered to ensure delivery of all ordered medications. The medication will be attached to the bubble pack card in the resident’s medication drawer; The replacement medication will be used with the next medication administration. Hospice residents not on cycle fill: Facility met with hospice as these residents were running out of medications and there was often a delay in getting a refill prescription from hospice and then filled from pharmacy. Hospice agreed to have these residents on cycle fill unless death is imminent. New orders entered with an incorrect start or end date: Staff will be better educated on the process for entering orders in PointClickCare, especially the details related to start and stop dates for new orders. Staff were unable to locate medications that were, in fact, available. Staff will be educated on the location of medications that are not in bubble packs, such as external medications (ear drops, eye drops, ointments), PRN medications, refrigerated medications, etc. Staff will be educated to contact the QMAP supervisor if they are unable to locate a medication. Family supplies a medication and medications ran out prior to obtaining a refill: This is a rare scenario and will now be tracked by the QMAP supervisor. Staff will be educated to document the action taken in the medical record if a medication is not available and to notify the POA and medical provider (cross reference tag 1600). The above information will be incorporated into new employee orientation for all future QMAPs. On business days, the Health Services Director, Resident Care Coordinator, and/or Administrator will monitor documentation of medications not administered in morning meeting using the following reports in PointClickCare: the 24-Hour Report for medications documented as not administered, such as refused or unavailable, and the Medication Admin Audit Report for missed medications. Copies of the reports will be maintained with documentation of investigations completed and actions taken. Corrective action will be taken with staff who do not follow correct facility policy. The Regional Nurse Consultant will review the results of the audits and actions taken with the administrator or designee monthly. Cross reference the plan of correction for tag 1606 related to quarterly audits by the Administrator and QMAP Supervisor as well as the plan of correction for tag 1600. Initial education was conducted on 7/9/24 with a majority of staff. The remainder of staff will be educated by 7/31/24. A completion date for remaining items: July 31, 2024

9999Final ObservationsSurveyor note▼

Findings

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Plan of correction

The state did not require a plan of correction for this citation.

6/18/2024Licensure and Licensure Complaint (Combined) · ID ZTHT1112 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey with complaints #CO35885 and #CO36392, were completed on 6/19/24. Deficiences were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0410Rpt Req-At Risk/Mndtry RprtS/S A▼

Findings

Based on record review and interview, the residence failed to report suspected sexual abuse to law enforcement within 24 hours of observation or discovery, affecting one of five sample residents (#17). (Cross reference S1320 and S1410)Findings include:1. Residence PolicyThe residence's Investigations of Abuse and Neglect policy dated May 2024, read in part: "allegations will be reported to the police or local law enforcement within 24 hours of the discovery of abuse."2. Resident #17 was admitted to the residence on 9/21/20 with a diagnosis of vascular dementia. Documentation of the investigation of abuse, read on 6/6 at 10:00 p.m. an allegation of sexual abuse was made by Staff #14 and #15, who alleged they had witnessed Former Staff #19 penetrate Resident #17 with his fingers while providing incontinence care. The documentation further read, the allegation was reported to law enforcement on 6/8/24.3. InterviewsOn 6/18/24 at 10:47 a.m., the administrator stated Staff #15 reported to the resident care coordinator (RCC) around 9:00 p.m. on 6/7, that she had witnessed Former Staff #19 open Resident #17's brief and placed his fingers inside her vagina to check for wetness during the evening shift on 6/6/24. The administrator stated she was made aware of the allegation by the RCC, on 6/7/24 at 9:32 p.m. The administrator stated the afternoon of 6/8/24 law enforcement was notified of the allegation. On 6/18/24 at 3:25 p.m., Staff #14 stated she witnessed Former Staff #19 placed his fingers "inside (Resident #17) vaginally" around 10:00 p.m. on 6/6/24. Staff #14 stated she reported the allegation to the RCC around 6:00 a.m. on 6/7/24. Staff #14 further stated she was trained to report allegations of abuse to the RCC and was not aware of the requirement to report to law enforcement within 24 hours. On 6/19/24 at 8:02 a.m., Staff #18 stated she had worked at the residence for a month and was trained to report all allegations of abuse to the RCC. Staff #18 stated she was unaware that she was required to report to law enforcement within 24 hours of any observed or alleged abuse. On 6/19/24 at 8:09 a.m., contrary to Staff #14's statement, the RCC stated she was informed of the allegation of sexual abuse by Staff #15 at 7:30 p.m. on 6/7/24, and had not heard from Staff #14 of the allegation until the RCC asked the staff member after Staff #15's report. The RCC stated the observed sexual abuse had occurred on Staff #15's previous shift around 10:00 p.m. on 6/6/24. She further stated she would have expected Staff #14 or #15 to have reported the allegation to herself or the administrator when the incident occurred on 6/6/24. The RCC stated residence personnel were trained to contact herself and the administrator of any allegations of abuse, since the administrator reported to law enforcement herself. On 6/19/24 at approximately 10:20 a.m., the administrator stated she was aware of the requirement for law enforcement to be notified within 24 hours of observed or alleged abuse. The administrator stated she would have expected the allegation to have been reported to law enforcement within 24 hours and stated Staff #14 or #15 should have reported to herself or the RCC when the incident was observed on 6/6/24. The administrator acknowledged she was unsure why law enforcement had not been notified until the afternoon of 6/8/24.

Plan of correction

The state did not require a plan of correction for this citation.

0648Prsnl-Stf/Vol Ornt/Trng SpcfcS/S A▼

Findings

Based on interview and record review, the residence failed to ensure each staff member completed training relevant to their specific duties and responsibilities prior to working independently for one former staff member (#19), affecting 36 current residents. (Cross reference S0664 and S1320) 1. Findings Include:Review of Former Staff #19's personnel file read Former Staff #19 was hired as a qualified medication administration person (QMAP). The personnel file revealed no evidence of training related to caregiving duties and responsibilities. There was no evidence Former Staff #19 was shown how to perform perineal care on incontinent residents. On 6/18/24 at 12:07 p.m., Former Staff #19 stated he was hired as a QMAP and had no experience with providing perineal care on incontinent residents and had not received training on incontinence care prior to working independently. Former Staff #19 stated due to there being less staff on night shift, he was informed by the resident care coordinator (RCC) he needed to help with incontinence care. The former staff member stated he had observed other staff members whose names he did not know, checking incontinent resident's briefs by squeezing the inside of the brief to check for wetness, so he did the same. On 6/18/24 at 3:57 p.m., the business office manager (BOM) stated Staff #16 provided on the job training to Former Staff #19 on incontinence care prior to him having worked independently. On 6/18/24 at 3:58 p.m., contrary to the BOM's statement, Staff #16 stated she had not observed or trained Former Staff #19 on incontinence care. Staff #16 stated QMAPs seldomly perform perineal care on residents and when she briefly informed Former Staff #19 that there were incontinent residents that required incontinence care, he stated he understood. On 6/19/24 at approximately 10:20 p.m., the administrator stated she was aware staff were required to receive training on job specific duties and would have expected that to have occurred. The administrator stated she was unaware why Former Staff #19 had not received training on incontinence care prior to providing care to residents.

Plan of correction · submitted by the facility

The employee (#19) is no longer employed at our community. All current and future residents have the potential to be affected. Please cross reference #1352 on the Incontinence Policy and Procedures and education/training.(Cross reference S0664 and S1320)Please cross reference #0664 for ways that we document the training and education. An orientation checklist will be completed for all new staff confirming completion of all new hire education prior to a new employee caring for residents on their own. The facility will ensure the orientation checklist is maintained in the employee file (cross reference the plan of correction for tag 0664). The completion date for all reeducation and future education will be July 31, 2024.

0664Prsnl-Prsnl Files RqS/S B▼

Findings

Based on the interview and record review, the residence failed to ensure personnel files included written documentation of orientation, training, and hire dates for two of three staff members (#13, #19), affecting 36 residents. (Cross reference S1332)Findings include:1. Record reviewThe personnel files for Staff #13 and Former Staff #19 were reviewed, revealing that neither staff member had a hire date. Former Staff #19's file did not contain any training documentation, and Staff #13's file did not contain any orientation documentation. 2. InterviewsOn 6/18/24 at 4:41 p.m., the resident care coordinator (RCC) said current qualified medication adminstration persons (QMAP) train incoming QMAPs. The RCC said Staff #19 did have the training but did not document it before contact with residents. On 6/19/24 at 10:20 a.m., the administrator said she did not know why staff member hire dates were not in the file. The administrator said staff should have had documented training in their file. The administrator said Former Staff #19 ' s training was not documented. The administrator said Staff #13 was a rehire, so some documentation was missing.

Plan of correction · submitted by the facility

(Cross reference S1332)Employee #19 no long works at the facility. A completed orientation checklist was obtained for Employee #13. All employee files were audited on 7/9/24 and it was identified that 9 employees did not have orientation checklists in their files, however, had completed new employee orientation. New orientation checklists will be recreated by the employee’s preceptor by 7/19/24. All employee files will have a cover page that lists their hire date and other pertinent employee information. Before an employee is scheduled to care for residents on their own, a completed and signed Orientation Checklist must be received for their personnel file. A copy will be made for the employee to retain for their records. The Business Office Coordinator will track the start and end dates for orientation/training for all new direct care workers and will alert the Administrator if an Orientation Checklist was not received. The employee will be taken off of the schedule until a completed and signed Orientation Checklist is received. A checklist of required items is used to determine if a new employee file is considered complete. Incomplete employee files will be kept in a separate type of folder in an alternate location from complete employee files. Once all required information is in the new employee file, the information will be moved from the temporary folder to an official employee file and placed with other employee files. This will help ensure better tracking of files that are still waiting on additional information. Monday through Friday during morning meeting, the Administrator asks about staffing. The administrator will now ask if there are any current employees in orientation and their estimated date of completion. The Administrator will remind the scheduler that the employee is not allowed to work on the floor until a completed and signed Orientation Checklist has been received and all training has been completed. The Business Office Coordinator will maintain a spreadsheet listing all new hires, their start date, their end date of orientation, the date their orientation checklist was received, the date they completed Relias First Aide training, and the first date they were scheduled to work on their own.,The administrator will review the tracking spreadsheet and incomplete employee files on at least a monthly basis with the Business Office Coordinator to ensure files are completed in a timely manner. July 31, 2024 will be the completion date

0732Stf Req-First Aid 1 Stf Onsite CrtfdS/S B▼

Findings

Based on interview and record review the residence failed to ensure there was at least one staff member onsite at all times certified in first aid, affecting 36 current residents. Findings include:On 6/18/24 at 9:58 a.m., first aid certifications for all staff were requested. On 6/18/24 at approximately 10:15 a.m., the administrator stated residence staff took cardiopulmonary resuscitation (CPR) and first aid training in the beginning of June of 2024; however, had not yet received the certificates. On 6/18/24 at 10:35 a.m., the first aid instructor confirmed the staff only completed basic life support training and not first aid training. The June 2024 staff schedule revealed the following shifts did not have at least one person certified in first aid as follows:6/9 from 6:00 a.m.-8:00 a.m. 6/13 from 6:00 a.m.-2:00 p.m. 6/9-6/15/24 from 10:00 p.m.-8:00 a.m. On 6/19/24 at 10:20 a.m.,the administrator stated she was not aware the course the staff members completed did not include first aid training and was only CPR training.

Plan of correction · submitted by the facility

All current and further residents have the potential to be impacted by this deficiency. All current staff who do not have First Aide training will be trained using Relias. New employees will be assigned the Relias First Aide training to complete during orientation. This will be added to the Orientation Checklist and will be completed prior to working on their own with residents. (Cross reference tag 0664)The Business Office Coordinator currently tracks completion of training in Relias by all staff. The Business Office Coordinator will ensure all new direct care employees complete Relias First Aide training prior to being scheduled on the floor to care for new residents. This will be confirmed at the same time the Orientation Checklist is received. Cross reference tag 0664. Trainings were held on June 29, 2024 and June 30, 2024 for staff to watch the Relias First Aide trainings in a classroom setting in the facility. Staff who were unable to attend those sessions will complete the Relias Training by July 31, 2024.

1320Res Rghts Rts/Rspn-Civ/Rel-Dig-RspctS/S B▼

Findings

Based on interviews and record review, the residence failed to ensure the residents received the cooperation of the residence to achieve the maximum degree of benefit, affecting four of four sample residents (#18-#21). Findings include:1. Resident #11 was admitted to the residence on 8/31/23. The May 2024 and June 2024 Response Time Report documented for Resident #11 read that she pressed her pendant nine times with wait times longer than 15 minutes, as follows:6/6/24 at 12:40 p.m. for 59 minutes6/7/24 at 1:37 p.m. for 33 minutes 6/10/24 at 1:37 p.m. for 57 minutes6/10/24 at 11:07 a.m. for 28 minutes6/11/24 at 12:21 a.m. for 33 minutes6/11/24 at 6:33 p.m. for 26 minutes6/11/24 at 7:58 p.m. for 33 minutes6/12/24 at 3:43 a.m. for 49 minutes 6/12/24 at 11:30 a.m. for 24 minutes 2. Resident #19 was admitted to the residence on 5/20/24The May 2024 and June 2024 Response Time Report documented for Resident #19 read that he pressed his pendant one time with wait times longer than 15 minutes, as follows:On 6/9/24 at 10:35 a.m. for 24 hours and 28 minutes. 3. Resident #20 was admitted to the residence on 11/30/23. The May 2024 and June 2024 Response Time Report documented for Resident #20 read that she pressed her pendant two times with wait times longer than 15 minutes, as follows:6/1/24 at 6:53 p.m. for 29 minutes6/4/24 at 7:24 p.m. for 45 minutes 4. Resident #18 was admitted to the residence on 10/15/21. The May 2024 and June 2024 Response Time Report documented for Resident #18 read that she pressed her pendant one1 time with wait times longer than 15 minutes, as follows:On 6/6/24 at 12:40 p.m. for 1 hour and 43 minutes 5. InterviewsOn 6/19/24 at 8:55 a.m., Staff #19 said the staff should answer the call pendant immediately within a few minutes. Staff #19 said answering quickly in case the resident had an emergency was important. Staff #19 said it was very difficult to answer call pendant timely because the residence was short staffed at times. On 6/19/24 at 8:59 a.m., the administrator stated resident pendant lights should be answered within 10 minutes.

Plan of correction

The state did not require a plan of correction for this citation.

1352Res Rghts Rts/Rspn-Choice/Invlv Cr/Svc-CommS/S B▼

Findings

Based on record review and interview the residence failed to ensure residents were treated with dignity and respect, affecting three of five sample residents (#14, #16, #17). (Cross reference S410, S648, S1410)Findings include:1. Residence PolicyThe residence's Resident Right policy, dated November 2017, read in part: "residents ... shall have the following rights: the right to be treated with respect and dignity."2. Record ReviewResident #17 was admitted to the residence on 9/21/20 with a diagnosis of vascular dementia. The residence's care plan for Resident #17, dated 4/29/24 read the resident was incontinent of both bowel and bladder and required staff to check the resident for incontinence every two hours and perform perineal care when soiled which included changing the resident's soiled brief and applying barrier cream. The residence's investigation of abuse, read on 6/11/24 Former Staff #19 stated he checked a resident for soiledness by putting his hand inside the brief to feel if it was wet if the resident was lying on their side, or putting two fingers inside the brief with the fingers curled up facing outward but not toward the resident and squeezing it for wetness. A letter of termination dated 6/12/24 read Former Staff #19 was terminated for violating resident rights. 3. InterviewsOn 6/18/24 at 12:07 p.m., Former Staff #19 stated he was hired as a qualified medication administration person (QMAP) and had no experience with providing perineal care on incontinent residents and had not received training on incontinence care prior to working independently. He stated he had observed other staff members check a resident for incontinence by squeezing the inside of a resident's incontinence brief and that was how he would check to see if a resident was soiled. On 6/18/24 at 3:35 p.m., Staff #17 stated she had observed Former Staff #19 put his hand in a resident's brief to check for it being soiled, but was unsure which resident it was. Staff #17 stated she had never observed Former Staff #19 touching a resident inappropriately; however, stated staff were trained to check a resident from outside the brief since a line would show up a different color on the outside when soiled. Staff #17 stated she felt Former Staff #19 checking a resident from inside the brief was "disrespectful" to the resident and "a violation of their rights."On 6/19/24 at 7:29 a.m., Resident #17's legal representative stated she was "disturbed" to hear how Former Staff #19 checked Resident #17 for soiledness, and stated although it was uncertain that what had occurred was sexual abuse, she felt it was a violation of Resident #17's rights. On 6/19/24 at approximately 10:20 a.m., the administrator stated staff were trained to check a resident for incontinence by observing the colored line change on the outside of the brief, or if unable to tell by squeezing the outside of the brief. The administrator stated she was unsure why Former Staff #19 had not been trained on incontinence care, and stated Resident #17 should not have been checked for incontinence from inside the brief. She further stated she expected residents to be treated with dignity and respect and stated by checking a resident for incontinence from inside the brief, Former Staff #19 had not respected the resident's rights. 4. There was similar deficient practice for Residents #14 and #16.

Plan of correction · submitted by the facility

(Cross reference POCD to Tags S410, S648, S1410)Former employee #19 was immediately suspended pending the investigation once the incident was reported to the administrator and terminated at the conclusion of the investigation. Former employee #19 no longer works at the facility and is not eligible for rehire, so current and future residents do not have the potential to be affected by this employee. Current and future residents have the potential to be affected by staff potentially performing incorrect incontinence care. All staff providing incontinence care will continue to be trained on proper incontinence care prior to caring for residents. The level of training will be commensurate with prior knowledge and experience. Of note, Former Employee #19 reported to the surveyor that he had no experience providing perineal care on incontinent residents and had not received training on incontinence care. The Regional Nurse Consultant performed the initial interview prior to hire with Former Employee #19 which lasted over an hour. Former Employee #19 described extensive care giving experiencing, including performing ADLs on elderly dementia care residents. In addition, Former Employee #19 spent multiple days shadowing experienced staff on the night shift, including while performing incontinence care of residents, prior to completing care on his own. An orientation checklist was completed as confirmed by the preceptor who trained him, however, unfortunately could not be located at the time of the survey. An orientation checklist will be completed for all new staff confirming completion of all new hire education prior to a new employee caring for residents on their own. The facility will ensure the orientation checklist is maintained in the employee file (cross reference the plan of correction for tag 0664). Staff will be trained to promptly report any concerns regarding the care provided by another staff member to the QMAP supervisor, nurse , and/or administrator (cross reference tag 1410). All current staff will be retrained on the facility policy, “Perineal Care“All current staff will be retrained on the proper procedure for checking a resident to determine if a brief is wet or soiled and needs to be changed. Proper procedure includes looking at the wetness indicator on the outside of the brief and/or squeezing the outside of the brief. If there is any doubt as to the degree of wetness or soilage of a brief, the brief shall be changed using proper technique per facility policy. At no time shall a staff member insert their fingers into a brief to determine if it is wet or soiled. This information will be incorporated into new employee orientation and added to the new employee orientation checklist. The RCC or designee will perform rounds to observe RAs performing checks on incontinent residents monthly. Observations shall include at least 8 resident observations each shift each month of a variety of staff and residents on all shifts, any new staff hired within the month, and any new incontinent residents admitted within the month. Initial education was conducted on 7/9/24 with a majority of staff. The remainder of staff will be educated by 7/31/24. A completion date for remaining items: July 31, 2024

1382Res Rghts-House Rules Violation/InclS/S B▼

Findings

Based on the record review and interview, the residence failed to address all the components required in the residence's house rules. Findings include:The administrator provided the house rules on 6/18/24. The house rules did not include house rules on smoking, including the use of electronic cigarettes and vaporizers or the consumption of alcohol and marijuana. On 6/19/24 at approximately 10:30 a.m., the administrator said she was unaware the house rules did not include house rules on smoking, including the use of electronic cigarettes and vaporizers, or the consumption of alcohol and marijuana. The administrator said the house rules should include these components.

Plan of correction · submitted by the facility

The below plan of correction will correct the deficient practice for the affected residents. All current and future residents have the potential to be affected. The House Rules will be updated and posted in the lobby and dining room areas in the communities and will be included in the admission packets for new residents. We will also go from room to room and pass out the printed House Rules. We will provide a copy to the responsible party for each current resident. We will also have a check off sheet to fill out for the residents and their responsible parties to ensure all were notified. The House Rules will be mentioned during a Resident Council session and residents will be shown where to locate them posted in our community. The Administrator will round in the facility monthly to ensure the House Rules continue to be posted in a visible location in each community. The Administrator will review a copy of the admission packet monthly to ensure the House Rules continue to be included in the admission packets for new residents. Dates for completion:July 3, 2024: House Rules were discussed to the residents during Resident Council. July 10, 2024: The updated House Rules were added to the admission packet for new residents. By July 31, 2024: All residents and their responsible parties will be given a copy of the House Rules and the tracker sheet will be completed.

1410Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S A▼

Findings

Based on record review and interview, the residence failed to investigate allegations of abuse in accordance with regulation and written policy, affecting one of five sample residents (#17). (Cross reference S410 and S1320)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following: (B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation.b. Chapter VII regulations governing assisted living residences, part 2.1, defines "Abuse" as any of the following acts or omissions:(C) Subjection to sexual conduct or contact that is classified as a crime.c. Chapter II regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein."d. The residence's Investigations of Abuse and Neglect policy, dated May 2024, read in part, the residence would identify and investigate all reported or alleged incidents of sexual abuse and allegations would be reported to local law enforcement, the department, adult protective services (APS) and the resident's emergency contact within 24 hours. During the investigation process the residence will ensure the resident is protected from potential future abuse. Documentation will be made available with appropriate measures instituted. 2. Resident #17 was admitted to the residence on 9/21/20 with a diagnosis of vascular dementia. Documentation of the investigation of abuse, read on 6/6 at 10:00 p.m. an allegation of sexual abuse was made by Staff #14 and #15, who alleged they had witnessed Former Staff #19 penetrate Resident #17 with his fingers while providing incontinence care. The documentation further read, the allegation was reported to Resident #17's legal representative, APS and the department at approximately 3:00 p.m. on 6/8/24.3. InterviewsOn 6/18/24 at 10:47 a.m., the administrator stated Staff #15 reported to the resident care coordinator (RCC) around 9:00 p.m. on 6/7, that she had witnessed Former Staff #19 open Resident #17's brief and placed his fingers inside her vagina to check for wetness during the evening shift on 6/6/24. The administrator stated she was made aware of the allegation by the RCC, on 6/7/24 at 9:32 p.m. The administrator stated the afternoon of 6/8/24, APS, Resident #17's legal representative and the department were notified of the allegation. On 6/18/24 at 3:25 p.m., Staff #14 stated she witnessed Former Staff #19 placed his fingers "inside (Resident #17) vaginally" around 10:00 p.m. on 6/6/24. Staff #14 stated she reported the allegation to the RCC around 6:00 a.m. on 6/7/24. Staff #14 further stated she was trained to report allegations of abuse to the RCC and was not aware of the requirement to contact a resident's legal representative or APS.On 6/19/24 at 7:20 a.m., the legal representative for Resident #17 stated she "was upset" because she was not notified of the allegation that occurred the night of 6/6, until 6/8 at 3:00 p.m. and had notified the external hospice provider on 6/9/24 to perform a rape test on Resident #17. The legal representative stated if she would have been notified on 6/6/24 a rape test at that time would provide more clear evidence whether the allegation occurred. On 6/19/24 at 8:09 a.m., contrary to Staff #14's statement, the RCC stated she was informed of the allegation of sexual abuse by Staff #15 at 7:30 p.m. on 6/7/24, and had not heard from Staff #14 of the allegation until the RCC asked the staff member after Staff #15's report. The RCC stated the observed sexual abuse had occurred on Staff #15's previous shift around 10:00 p.m. on 6/6/24. She further stated she would have expected Staff #14 or #15 to have reported the allegation to herself or the administrator when the incident occurred on 6/6/24. The RCC stated residence personnel were trained to contact herself and the administrator of any allegations of abuse, since the administrator reported to APS, legal representatives and the department herself. On 6/19/24 at approximately 10:20 a.m., the administrator stated APS, the department and legal representative were notified within 24 hours of when she was made aware, and was aware of the requirement. The administrator further acknowledged Staff #14, #15 or the RCC should have notified the required contacts within 24 hours of the allegation.

Plan of correction · submitted by the facility

Former employee #19 was immediately suspended pending the investigation once the incident was reported to the administrator and terminated at the conclusion of the investigation. Education was provided on June 7, 2024 with staff #14 and #15 regarding timely reporting of concerns related to care, including potential abuse and/or neglect in order to ensure timely investigation and reporting. All current and future residents have the potential to be affected. We had an emergency reeducation for all staff on June 14, 2024 and June 17, 2024, which included a hands-on education of how to check incontinent residents properly per policy to ensure all residents’ rights are not violated and dignity is maintained. We also provided verbal and written education on all forms of abuse and neglect. See attached forms for information and training logs. Additional education: Cross reference tag 1352 for additional education related to training on incontinence care. Cross reference tag 2230 related to documentation of pertinent resident events in the medical record. All current staff have been educated on the importance of immediately reporting any witnessed concerns related to the care or treatment of residents to their immediate supervisor and any concerns that in any way could be considered potential abuse or neglect will be reported immediately to the administrator. If after hours, the on-call manager will be notified. The administrator or on-call manager will immediately begin an investigation to determine if the criteria for potential abuse or neglect has been met and will follow facility policies and procedures for further action. Education will be included in new employee orientation for all new employees. Care concerns received from any source by anyone in the facility are written on a concern form. The form has been revised to include the date and time the concern was observed in addition to the date and time the concern was reported. A box will be added to indicate if the concern was reported in a timely manner. Results of the facility investigation are documented on the care concern forms. Follow-up action will be taken with staff who do not report care concerns timely. Cross reference tag 1352 for training and on-going monitoring related to appropriate incontinence care. Cross reference tag 2230 related to reviewing/monitoring pertinent out of the ordinary resident events or issues on an ongoing basis to determine if further investigation and reporting is indicated. Cross reference tag 0410 related to mandatory reporting of suspected abuse or neglect. The Administrator or designee will monitor all reported resident care concerns daily Monday through Friday to determine if they were reported timely and to ensure appropriate investigation and follow-up action. The Regional Nurse Consultant will review all care concern forms monthly that related to resident care or treatment to determine if they were reported timely and if appropriate investigation and follow-up action was taken. A trending of the care concern forms and actions taken will be reported at least quarterly to the facility quality assurance and performance improvement meeting on an on-going basis and further action taken as the determined by the committee. June 14, 2024, Emergency Abuse and Neglect reeducation and Peri Care overview and hands on training. June 17, 2024, any employees who missed the training was completed. Additional training was held on July 9, 2024 on the importance of timely reporting of care concerns and potential abuse/neglect. Additional training for staff who did not attend will be completed b July 31, 2024. The care concern form will be revised by July 15, 2024 to add a spot for date/time concern was witnessed for resident direct care concerns and a spot to check if the concern was reported timely. July 26, 2024, The Weld County ombudsman team will be conducting a training event for all staff on Abuse, Neglect, timely reporting and the warning signs. August 7, 2024, The Weld County Ombudsman team will also be conducting the same training but to the families of our residents.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting three of four (#5, #17, #14) sample residents. Findings include:1. Resident #5 was admitted to the residence on 9/12/22 with diagnoses including dementia.a. AcetaminophenA written practitioner's order, dated 5/13/24, directed the residence to administer acetaminophen 650 mg extended release one tab BID (two times a day). However, the May 2024 and June 2024 medication administration records (MARs) read that the residence failed to administer the medication in the morning on 5/18/24-5/20/24, 5/22/24-5/27/24, 6/11/24, and in the evening on 5/17/24-5/26/24, for a total of 20 missed doses due to the medication being unavailable. The MAR documented the medication as arthritis pain relief. However, the resident care coordinator said it was acetaminophen.b. Anti-diarrhealA written practitioner's order, dated 8/1/24, directed the residence to administer anti-diarrheal 2.5 mg one tab twice daily. However, the May 2024 and June 2024 MAR read that the residence failed to administer the medication on both doses on 5/5/24,5/23/24,5/25/24-5/30/24, 6/1/24,6/2/24,6/4/24-6/8/24 and the evening dose on 5/24/24 and 6/3/24, for a total of 32 missed doses due to the medication being unavailable.c. Citalopram HydrobromideA written practitioner's order, dated 1/18/23, directed the residence to administer citalopram hydrobromide 40 mg tablet once daily. However, the May 2024 and June 2024 MAR read that the residence failed to administer the medication on 5/5/24, 5/7/24-5/10/24, 5/27/24-5/30/24, 6/1/24, and 6/4/24-6/13/24 for a total of 20 missed doses because the medication was unavailable.d. RisperidoneA written practitioner's order, dated 10/13/23, directed the residence to administer risperidone 0.25 mg tablets BID. However, the May 2024 MAR read that the residence failed to administer both doses 5/5/24, 5/22/24, 5/23/24, 5/25/26/24, the morning dose on 5/27/24 and the evening dose on 5/24/24, for a total of 11 missed doses due to the medication being unavailable.e. SpironolactoneA written practitioner's order, dated 1/18/23, directed the residence to administer spironolactone 25 mg tablet every morning related to heart failure. However, the May 2024 MAR read that the residence failed to administer the medication on 5/5/24, 5/7/24- 5/10/24, 5/26/24 and 5/27/24 for a total of eight missed doses because the medication was unavailable.f. TramadolA written practitioner's order, dated 1/18/23, directed the residence to administer tramadol 50 mg tablet and give 0.5 tablet twice daily. However, the May 2024 and June 2024 MAR read that the residence failed to administer the medication of both doses on 6/10/24-6/13/24 and the morning dose on 5/7/24, for a total of seven missed doses due to the medication being unavailableOn 6/18/24 at 7:50 a.m., Staff #13 said the residence did not have a process to ensure medications did not run out. She said she notified the pharmacy if she noticed the resident had seven days left of medication. Further, Staff #13 stated if a medication were unavailable, she documented it in the MAR. On 6/19/24, at approximately 10 a.m., the administrator said qualified medication administration person (QMAP) should follow the practitioner's orders. She stated QMAPs contacted the nurse or pharmacy to get more medications if a medication was out. The administrator said she understood the residence's responsibility was to ensure the residents had all their medications in stock. 2. Additionally, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration for Resident #17 and Resident #14.

Plan of correction · submitted by the facility

Resident #17 no longer resides in the facility. Residents #5 and #14 were included in the audit conducted for all residents on 7/9/24 and all medications were available to be administered. All current and future residents have the potential to be impacted. An audit was conducted on 7/9/24 and all residents had all medications available to be administered. An investigation was conducted on 7/1/24-7/2/24 by the Regional Nurse Consultant and Resident Care Coordinator to determine the root causes of why medications may not be available. Systems were created to improve the availability of medications and staff will be educated to those systems, to include: Medications on cycle fill but a pill had to be wasted for various reason (medication contaminated and a new medication dispensed, resident spit out and another medication dispensed, etc.) and a replacement medication was not ordered, so medications were short at the end of the cycle fill. A new process was implemented for a replacement medication to be ordered at the time an extra medication is dispensed. A “Pharmacy Communication: Replacement Medication Request“ will be faxed to the pharmacy when a replacement medication is needed. The form will be placed in a pink folder in the top bin of the triple check bins; The forms will be compared with medications delivered to ensure delivery of all ordered medications. The medication will be attached to the bubble pack card in the resident’s medication drawer; The replacement medication will be used with the next medication administration. Hospice residents not on cycle fill: Facility met with hospice as these residents were running out of medications and there was often a delay in getting a refill prescription from hospice and then filled from pharmacy. Hospice agreed to have these residents on cycle fill unless death is imminent. New orders entered with an incorrect start or end date: Staff will be better educated on the process for entering orders in PointClickCare, especially the details related to start and stop dates for new orders. Staff were unable to locate medications that were, in fact, available. Staff will be educated on the location of medications that are not in bubble packs, such as external medications (ear drops, eye drops, ointments), PRN medications, refrigerated medications, etc. Staff will be educated to contact the QMAP supervisor if they are unable to locate a medication. Family supplies a medication and medications ran out prior to obtaining a refill: This is a rare scenario and will now be tracked by the QMAP supervisor. Staff will be educated to document the action taken in the medical record if a medication is not available and to notify the POA and medical provider (cross reference tag 1600). The above information will be incorporated into new employee orientation for all future QMAPsOn business days, the Health Services Director, Resident Care Coordinator, and/or Administrator will monitor documentation of medications not administered in morning meeting using the following reports in PointClickCare: the 24-Hour Report for medications documented as not administered, such as refused or unavailable, and the Medication Admin Audit Report for missed medications. Copies of the reports will be maintained with documentation of investigations completed and actions taken. Corrective action will be taken with staff who do not follow correct facility policy. The Regional Nurse Consultant will review the results of the audits and actions taken with the administrator or designee monthly. Cross reference the plan of correction for tag 1606 related to quarterly audits by the Administrator and QMAP Supervisor as well as the plan of correction for tag 1600. Initial education was conducted on 7/9/24 with a majority of staff. The remainder of staff will be educated by 7/31/24. A completion date for remaining items: July 31, 2024

1600Med/Med Adm-Rcrd Kpng MARS/S B▼

Findings

Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting two of four sample residents (#5, #17) whose medications were reviewed. Findings include:1. Residence PolicyThe residence's Medication Administration policy dated May 2024, read in part, medication shall be administered in accordance with regulation and all administered medications shall accurately be recorded in the resident's record. 2. Resident #17 was admitted to the residence on 9/21/20 with a diagnosis of vascular dementia.a. GuaifenesinA written practitioner's order dated 5/22/24, directed the residence to administer guaifenesin 100 mg three times a day for seven days. However, the June 2024 electronic medication administration record (eMAR), read on 6/4 in the afternoon the medication was no longer available because all the medication had been administered. However, staff marked the medication as administered 6/5 for all three doses, and 6/6, 6/7 and 6/8/24 in the evening, for a total of six inaccurately documented doses.b. SertralineA written practitioner's order dated 3/22/24, directed the residence to administer sertraline 25 mg daily. However, the May 2024 eMAR contained a code "9" which read to see progress notes on 5/6/24. However, there was no corresponding progress note, for a total of one inaccurately documented dose. On 6/19/24 at approximately 10:20 a.m., the administrator stated she would have expected staff to only document guaifenesin as administered for seven days as ordered. She acknowledged staff should not have documented guaifenesin as administered after the medication was documented to have been out of stock. She further stated she would expect staff to document accurate information on the eMARs at the time of administration. The administrator stated code "9" on the eMAR for "other see progress notes" should correspond with a progress note and the eMAR should accurately reflect all practitioner's orders. 3. There was similar deficient practice for Resident #5.

Plan of correction · submitted by the facility

For resident #17 and #5: These documentation omissions/errors were in the past, so they are unable to be corrected for these residents. The below plan of correction will include all staff and these residents to reduce the risk of future errors or omissions for these residents. All current residents have medication orders, so have the potential to be impacted. All staff will be educated on the facility policy “Medication Administration“ with an emphasis on correct documentation of all medications administered, as well as the reason if a medication is not administered. All staff will be educated on tips and strategies for medication administration with dementia residents. This information will be incorporated into new employee orientation. Cross reference the plan of correction for tag 1568 for additional measures. On business days, the Health Services Director, Resident Care Coordinator, and/or Administrator will monitor documentation of medications not administered in morning meeting using the following reports in PointClickCare: the 24-Hour Report for medications documented as not administered, such as refused or unavailable, and the Medication Admin Audit Report for missed medications. Copies of the reports will be maintained with documentation of investigations completed and actions taken. Corrective action will be taken with staff who do not follow correct facility policy. The Regional Nurse Consultant will review the results of the audits and actions taken with the administrator or designee monthly. Cross reference the plan of correction for tag 1606 related to quarterly audits by the Administrator and QMAP Supervisor as well as the plan of correction for tag 1568. Initial education was conducted on 7/9/24 with a majority of staff. The remainder of staff will be educated by 7/31/24. A completion date for remaining items: July 31, 2024

1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based on interviews and record reviews, the residence failed to ensure the administrator and qualified medication administration supervisor audited the accuracy and completeness of the medication administration records affecting 36 residents. 1. Record review On 6/18/24, quarterly medication audits were requested from the administrator and provided. However, the medication audits were completed by the qualified medication administration supervisor but did not include the administrator. 2. InterviewOn 6/19/24 at 10:20 a.m., the administrator said she was unaware of the regulation and did not complete the audits, as required.

Plan of correction · submitted by the facility

See the below corrective action as all residents are at risk of being impacted. The administrator and QMAP supervisor will audit on at least a quarterly basis the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. The administrator and QMAP supervisor will be educated by the Regional Nurse Consultant on how to perform the required audits, including reports available in PointClickCare to assist with some audits. Any irregularities will be investigated and resolved. Results of the audits/reports, investigations, and corrective actions taken will be maintained by the administrator and included quarterly at the facility QAPI meetings and additional action taken as indicated. The Regional Nurse Consultant will review the results of the audits/reports, investigations, and corrective actions quarterly with the administrator to ensure completeness and to assist with additional potential systemic actions to ensure sustained and/or improved compliance. Education was completed on 7/9/24 by the Regional Nurse Consultant with the Administrator and QMAP Supervisor on the above process and a tool was implemented for tracking and trending the results of the audits. A completion date for remaining items: July 31, 2024

2230HIR-Cntnt IncldS/S A▼

Findings

Based on interview and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed or was reported to them, affecting one of five sample residents (#17). Findings include:1. Resident #17 was admitted to the residence on 9/21/20 with a diagnosis of vascular dementia. Documentation of the investigation of abuse, read on 6/6 at 10:00 p.m. an allegation of sexual abuse was made by Staff #14 and #15, who alleged they had witnessed Former Staff #19 penetrate Resident #17 with his fingers while providing incontinence care. However, there was no evidence of a progress note in Resident #17's record for the incident on 6/6/24.2. InterviewsOn 6/18/24 at 3:25 p.m., Staff #14 stated she witnessed Former Staff #19 placed his fingers "inside (Resident #17) vaginally" around 10:00 p.m. on 6/6/24. Staff #14 stated she was aware of the requirement to make a progress note prior to the end of her shift and stated she made a "paper report."On 6/18/24 at 3:35 p.m., Staff #17 stated she thought whenever anything out of the ordinary occurred she was supposed to inform the resident care coordinator and she would make a progress note. Staff #17 stated she was not trained on making a progress note in the electronic medical record system. On 6/18/24 at 3:56 p.m., the administrator stated she was unable to find a progress note of the alleged observation of sexual abuse that occurred on 6/6/24. The administrator stated she would have expected Staff #14 or #15 to have written a progress note of what they allegedly witnessed prior to the end of their shift. On 6/19/24 at 10:30 p.m., the administrator stated anyone that worked at the residence was capable of writing a progress note. The administrator stated a progress note should be written when anything out of the ordinary was observed.

Plan of correction · submitted by the facility

Resident #17 no longer resides at the facility. All current and future residents in the facility have the potential to be affected. All Resident Assistants will be educated to report any out of the ordinary event or issue that they personally observed to the QMAP on duty at the time. All QMAPs will be educated to document prior to the end of the shift any out of the ordinary event or issue regarding a resident that they personally observed or that was reported to them. In particular. QMAPs will be educated on the facility “Documentation Guidelines“ which contain specific instructions on when and how to document. Information will be included in new employee orientation for all future QMAPs. Cross reference plan of correction for tag 1410 related to reporting pertinent events to supervisor for timely investigation. On business days, the Health Services Director, Resident Care Coordinator, and/or Administrator will review documentation to ensure pertinent out of the ordinary events and changes in condition are documented in the resident’s record. Follow-up education will be completed with staff and late entries will be made in the medical record when documentation is missing. Documentation of the action taken with staff will be made by the QMAP supervisor and available for review monthly by the Regional Nurse Consultant. Cross reference plan of correction for tag 1410 related to reporting pertinent events to supervisor for timely investigation. A summary of the results of actions taken will be reported monthly to the facility QAPI meetings and further action taken as indicated. Initial education was conducted on 7/9/24 with a majority of staff. The remainder of staff will be educated by 7/31/24. A completion date for remaining items: July 31, 2024

9999Final ObservationsSurveyor note▼

Findings

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.

Plan of correction

The state did not require a plan of correction for this citation.

3/13/2024Licensure Complaint · ID 6FNM11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO35157, was completed on 3/14/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1/31/2024Licensure Complaint · ID KS5I11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO34763 and #CO34798, was completed on 1/31/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

10/24/2023Licensure Complaint · ID FENB111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO33997, was completed on 10/24/23. A deficiency was cited. The residence was licensed as a secure environment which served residents with cognitive impairment.

Plan of correction

The state did not require a plan of correction for this citation.

1312Res Rghts Rghts/Rspn-Civil/ReligS/S C▼

Findings

Based on record review and interview the residence failed to observe residents' right to live free from neglect, affecting one of three sample residents (#12). Specifically, on 10/1/23 at approximately 5:00 a.m., Resident #12 cried out for staff assistance and reported that she fell overnight and complained of head and neck pain. Staff #11 and Former Staff #13 lifted the resident from a seated position on the floor to her recliner in a seated position, despite the resident's complaints of head and neck pain and contrary to the residence's policy and regulation. The residence failed to provide adequate medical care, as staff failed to call emergency medical services after the resident reported at 5:00 a.m. Further, the overnight staff failed to notify day shift staff of the fall. Day shift staff were not notified of the fall until the resident's family member asked the day shift about the fall when they visited the resident that morning at approximately 8:00 a.m. The resident reported pain to the family member and was wincing with movement. Subsequently, the family, not the residence, decided to transfer Resident #12 to the hospital approximately three hours later and the resident was diagnosed with a closed nondisplaced fracture of the second cervical vertebra as a result of the fall. The resident also had bruising to her right hand. Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.10, defines caretaker neglect as, neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person.b. Chapter VII regulations governing assisted living residences, part 2.7, "At-risk person" means any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (F) Is mentally impaired as defined in Section 24-34-501(1.3)(b)(II), C.R.S.c. Chapter VII regulations governing assisted living residences, part 12.17, requires that the assisted living residence shall ensure that it has trained staff available to evaluate residents who have fallen or are otherwise unable to independently get up off the floor and provide lift assistance when determined appropriate instead of relying on emergency medical responders.(A) Each situation shall be evaluated to determine if the resident can be assisted in a safe manner such as when the resident has no pain and/or there is no change from baseline, the resident's mental status is unchanged from baseline, and there is no, or minor, bleeding.(B) Once the situation has been evaluated, assisted living residence policy shall require staff to take the following actions:(1) Physically perform the lift assistance using techniques provided in staff training and monitor the resident; or(2) Not lift and call 911 when the resident is unconscious, the resident's physical or mental status has declined from baseline, the resident experiences an increase in pain when lifting is attempted, the resident wants 9-1-1 called, and/or the resident either can't assist in any way or refuses to assist because of pain, injury, or other physical complications.(C) The assisted living residence shall promptly notify the resident's practitioner, family and/or legal representative of the occurrence of either circumstance identified in Part 12.17(B)(1) or (2), along with information regarding the ALR's response.d. Chapter VII regulations governing assisted living residences, part 18.8, requires that resident records shall contain, but not be limited to,the following items:(D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs;(1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them.e. The residence's resident rights policy, dated 11/2017, read in part, "Residents have the right to be free from neglect."f. The residence's undated Lift Assistance Policy, read in part: "All staff will be trained on what to do after a fall occurs and when to call lift assist to assist after an injurious or complicated fall ... staff member who finds the resident after a fall will first assure the resident's comfort and safety ... notify the qualified medication administration person (QMAP) or the nurse, observe for any injury and evaluate if the resident is able to get up ... determine if assisting the resident up from the fall is safe for all involved ... if the resident is experiencing pain staff will call 911 or lift assist dispatch for assistance ... once the resident has been assisted, the physician and resident's legal representative will be notified of the fall and outcome ... "g. The residence's undated Lifting, Resident Transfer, and Body Mechanics Policy, read in part: "to ensure the safe transfer of residents from one location or position to another... resident laying or sitting on the floor never move a resident after if they are complaining of any pain ... call 911, keep resident as comfortable as possible and wait for paramedics to assess ... "2. InterviewsOn 10/24/23 at 8:04 a.m., Staff #7 stated she came on shift on 10/1/23 at 6:00 a.m. after Resident #12 had a fall on 10/1/23 which happened during the night shift. She said there was no report or communication about Resident #12's fall at shift change from overnight staff. Staff #7 said, "I did not know about the fall until the family asked me about the fall when they came to visit with the resident." Staff #7 stated she went and checked on the resident after family reported the fall and Resident #12 complained of pain in her head and neck." She said the family decided to transport the resident to the emergency department. Staff #7 reported the fall to the administrator after the family reported it to her and contacted overnight staff to get details of the event because no incident report had been completed at that time. On 10/24/23 at 12:05 p.m., the administrator stated she was notified about Resident #12's fall on 10/1/23 at approximately 8:00 a.m. after the family told the day staff that Resident #12 was complaining of pain. The administrator added, during her internal investigation she was told Resident #12 had an unwitnessed fall on 10/1/23 at approximately 5:00 a.m and that Former Staff #13 heard Resident #12 crying out for help and found her on the floor. The administrator was told Former Staff #13 went and got Staff #11 and they lifted the resident together into her chair. The administrator stated, "I expect staff to follow the lift policy. Staff are trained to evaluate and if a resident was complaining of pain they were supposed to call 911 immediately." The administrator said, "I would have expected (Resident #12) to be sent out immediately if head pain had been reported at the initial time of the fall." Contrary to the internal investigation notes and the incident report both signed by the administrator that documented the resident experienced pain at the time of the fall at approximately 5:00 a.m., she stated, "It was not neglect because (Resident #12) did not mention pain at the time of the fall."On 10/24/23 at 12:42 p.m., a family member of Resident #12 stated she was visiting with Resident#12 on 10/1/23 at approximately 8:00 a.m. when Resident #12 stated she had fallen in the night and complained of pain and winced while moving. The family member added she went to ask staff what happened and why Resident #12 reported she was in pain. The family member was told by staff they were unaware the resident had fallen and would need to ask overnight staff what happened. The family member said she transported Resident #12 to the hospital at approximately 9:00 a.m. where Resident #12 was diagnosed with a cervical vertebra fracture. She added the administrator followed up with her later in the day and that was the first information she had received from the residence about the fall. The administrator told the family member that Resident #12 fell around 5 a.m. and the staff picked her up and placed her in the chair. The family member said the administrator reported that staff did not document the incident and had not reported the fall at the time of incident. On 10/24/23 at 12:58 p.m., Former Staff #13 stated, "I was completing 5:00 a.m. rounds with (Staff #11) and I was walking to get some supplies from the office when I heard (Resident #12) crying for help. I went into her room and found her on the floor and she told me her neck was hurting." Former Staff #13 stated she yelled for Staff #11 and stayed with the resident. Former Staff #13 stated that "(Resident #12) expressed pain to (Staff #11) while being assessed, then (Staff #11) instructed me to help lift the resident into the chair." Former Staff #13 stated, "I followed the lead of (Staff #11) to lift Resident #12 however I would have expected (Resident #12) to have been sent out because she complained of pain in her neck to me and (Staff #11)". Former Staff #13 explained that (Staff #11) was responsible for the reporting and documenting the fall, however, "(Staff #11) complained about having a migraine and it slipped her mind."On 10/24/23 at 3:43 p.m. the former health services director stated Former Staff #13 called her and said that Resident #12 had fallen on the overnight shift and that Resident #12 complained of pain. She added she was told by Former Staff #13 that Resident #12 was, "laying kind of funny and complaining of head and neck pain when found." 3. Resident #12 was admitted to the residence on 4/27/22 with diagnoses including dementia. The resident was 90 years old. Staffing schedule for October 2023 detailed shift change at 6:00 a.m. from overnight to day shift. An incident report, dated 10/1/23 at 7:00 a.m., detailed an unwitnessed fall with injury to the side of right hand bruised/neck pain. The report read in part, "(Resident #12) reported a fall she had overnight (5:00 a.m.) complaining of neck and back pain."Progress notes revealed no checks or reports were documented on the resident until 6:37 p.m. detailing the resident was back from the hospital at 6:37 p.m. and read in part, "(family member) let me know that the resident has a fractured neck." The hospital discharge summary, dated 10/1/23 at 3:20 p.m., read a diagnosis of "closed nondisplaced fracture of second cervical vertebra."A text message from Former Staff #13, dated 10/1/23 at 6:37 p.m., read in part "Heard (Resident #12) screaming so I checked on her she was sitting with her back to the front of the recliner said that she fell and her head was hurting so I told (Staff #11) and (Staff #11) came and checked her head out and helped me pick her up and sit her back in her recliner."Internal Investigation notes from the administrator, signed and dated 10/5/23, read in part, "(Former Staff #13) explained that she was in the health services office and heard (Resident #12) yelling for help at around 5:00 a.m. (Former Staff #13) stated that she found the resident sitting on the floor in front of her chair. (Former Staff #13) notified (Staff #11) and they both offered the resident to get back into her chair. Resident showed signs of pain at this time."

Plan of correction · submitted by the facility

Tag 1312: S/S: C Resident Rights and Responsibilities- Civil/Religious Requirement: Must observe resident rights in the care, treatment, and oversight of the residents. Failed to observe resident’s right to live free from neglect, affecting one of three sample residents (#12). She fell on 10/1/23/at 05:00 and complained of head and neck pain. Staff #11 and Staff #13 lifted the resident from a seated position on the floor to her recliner in a seated position, despite the resident’s complaints of head and neck pian and contrary to the residence’s policy and regulation. The residence failed to provide adequate medical car, as staff failed to call emergency medical services. Day shift staff were not notified of the fall until the resident’s family member asked the day shift about the fall when they visited the resident that morning at approximately 08:00. The resident reported pain to the family member and was wincing with movement. Subsequently, the family, not the residence, decided to transfer Resident #12 to the hospital approximately three hours later and the resident was diagnosed with a closed nondisplaced fracture of the second cervical vertebra. Plan of Correction:• Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Resident #12 was treated on 10/2/23 in the emergency department and returned to the facility later that day with a neck brace. She was placed on alert charting and her care plan was updated. On 10/20/23, a referral was made for hospice care due to an overall progressive decline in status that began prior to her fall and fracture. Her care is currently being managed by an RN case manager with hospice and staff at the facility are following the hospice care plan as well as the facility care plan. • Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All current residents who experience a fall have the potential to be affected.• Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:The facility Fall Policy was revised to include more detailed instructions for staff on procedures to follow post fall, including when to not move a resident and call 911. All staff will be educated on the revised Fall Policy. • Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:All falls are reviewed in morning meeting the following business day by the Interdisciplinary Team on an ongoing basis. An audit tool will be used to list all falls and will indicate if the resident experienced any pain or had evidence of an injury. If so, the fall will be reviewed to determine if the appropriate action was taken by staff at the time of the fall based on the Fall Policy. Follow-up action will be taken with staff if the Fall Policy was not followed. Results of the audits and all follow-up actions will be reviewed for at least three months at the facility QAPI meetings and longer if indicated. • Include dates when corrective action will be completed:The Fall Policy was revised 11/25/23. Education of all staff will be completed by 12/24/23.

9/13/2023Revisit: Licensure Complaint · ID 6SVJ122 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 9/14/23 for all previous deficiencies cited on 12/14/22. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S A▼

Findings

Based on observation, interview, and record review, the residence failed to either directly or indirectly through a resident agreement provide personal services, affecting one sample resident (#5) and one former resident (#10). Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.3, defines "Activities of daily living (ADLs)" as those personal functional activities required by an individual for continued well-being, health and safety. As used in this Chapter 7, activities of daily living include, but are not limited to, accompaniment, eating, dressing, grooming, bathing, personal hygiene (hair care, nail care, mouth care, positioning, shaving, skin care), mobility (ambulation, positioning, transfer), elimination (using the toilet) and respiratory care.b. Chapter VII regulations governing assisted living residences, part 2.34, defines "Personal services" as those services that an assisted living residence and its staff provide for each resident including, but not limited to:(A) An environment that is sanitary and safe from physical harm,(D) Assistance with activities of daily living.c. Chapter VII regulations governing assisted living residences, part 2.9, defines a "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual's need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual's needs. In order to deliver person-centered care, the care plan shall take into account the resident's preferences and desired outcomes. "Care plan" may also mean a service plan for those facilities which are licensed to provide services specifically for the mentally ill.d. The residence's resident agreement, dated September 2022, read, "A qualified staff member of the community will conduct an assessment and, with you, develop a service plan agreement. Community staff will then be responsible for assisting with these services and may include but are not limited to bathing and washing hair, dressing and undressing, grooming ... toileting ... according to your care level. The community is staffed 24 hours a day with qualified ... resident aides to meet your personal care needs." 2. Resident #5 was admitted to the residence on 9/12/22. A care plan for Resident #5, dated 4/11/23 read Resident #5 required two staff to assist her to the toilet. The care plan did not address how often Resident #5 was required to be toileted by staff. On 9/13/23 at approximately 7:30 a.m., Staff #7 said the last time Resident #5 was checked for incontinence and changed was during rounds at 6:00 a.m. She added the next time Resident #5 was checked and changed would be 9:00 a.m. On 9/14/23 at 8:49 a.m., an external hospice representative stated, "A lot of the times in the mornings she is saturated with urine."On 9/14/23 at approximately 9:15 a.m., Resident #5 was lying in bed awake. Her incontinence product was wet with urine. On 9/14/23 at approximately 11:30 a.m., the administrator stated she expected residents to be cleaned throughout the night and not be saturated with urine in the morning. 3. Former Resident #10 was admitted to the residence on 8/8/23. There was an undated RN (registered nurse) comprehensive initial assessment in the record for Former Resident #10 that read Former Resident #10 required staff to demonstrate teeth brushing and he needed cues from staff when he dressed and undressed for the day. There was no task listed for assistance with showering. A care plan in the record for Former Resident #10, dated 8/9/23, read Former Resident #10 needed assistance with teeth brushing and showers. A documentation survey report in the record for Former Resident #10, dated August 2023, had blank spaces for oral care assistance on 8/8/23 in the morning and evening and in the morning on 8/10 and 8/16/23. There was nothing listed about shower completion. There was no care task created that read Former Resident #10 received assistance with dressing or undressing. A document written by a family member of Former Resident #10, dated 8/31/23, read, "From August 8th - August 25th, (Former Resident #10) had one shower which was given to him by his (family member). From August 8th - August 25th, (Former Resident #10) never had his teeth brushed. (Family member) found the foil on the (unopened) toothpaste on the morning of August 12th ... From August 8th - August 25th, (Former Resident #10's) room had not been cleaned. The trash had been emptied, but his toilet, shower and floor were filthy."a. InterviewsOn 9/13/23 at 10:47 a.m., a family member of Former Resident #10 said on 8/21/23 that Former Resident #10 was found naked in his room. She added there were no fresh sheets on the bed so he was unable to lay in bed if he wanted to because it was not made. On 9/14/23 at 8:01 a.m., a family friend of Former Resident #10 said, "I don't think he got a shower at all. He smelled like he wasn't getting good hygiene. His (family member) had said staff were supposed to be helping him with showers. I told her to ask the facility about shower days. She ended up telling me that she gave him a shower herself. At least one shower by the (family member)."On 9/14/23 at 9:50 a.m., the administrator stated she was not aware Former Resident #10 had only received a shower from his family member and not from the staff. On 9/14/23 at approximately 11:30 a.m., the administrator stated there were care tasks listed in the computer for care staff to sign off on that they were completed. She added there was no follow up completed by the resident care coordinator if tasks were not completed.

Plan of correction · submitted by the facility

Tag Q1110: S/S: A Resident Care Services- Minimum Services, Resident Agreement (page 6)Requirement: Must provide services sufficient to meet resident needs. Failed to provide personal services for one current resident (#5) and one former resident (#10)Resident #5: Care plan dated 4/11/23 states required 2 staff to assist to toilet, did not address how often she required to be toiletedOn 9/13/23, was toileted at 06:00 and staff said the next time she would be checked and changed would be 09:00On 9/14/23, hospice representative stated she was often saturated with urine; at 09:15 that day her brief was wetFormer resident #10: Undated initial RN comprehensive assessment in the record read resident required staff to demonstrate teeth brushing and needed cues from staff when he dressed and undressed for the day; there was no task listed for assistance with showeringCare plan dated 8/9/23 stated he needed assistance with teeth brushing and showersDocumentation Survey Report dated Aug 2023 had blank spaces for oral care assistance on 8/8/23 in morning and evening and in the morning 8/10 and 8/16/23. There was nothing listed for shoer completion. There was no task to assist with dressing or undressing. Document written by a family member dated 8/31/23 stated from 8/8-8/25, resident had one shower which was given to him by his family member, he never had his teeth brushed (foil was still on the unopened toothpaste in am of 8/12), and his room had not been cleaned and toilet and shower were filthy. Per family member, on 9/13/23 at 10:47 he was naked in his room and there were no fresh sheets on the bed so he was unable to lay in bed if he wanted as it was not madeOn 9/14/23, family friend stated they didn’t think he ever got a shower at all as he smelled like he wasn’t getting good hygiene. She reported giving him a shower herself. On 9/14/23 at 09:50, the administrator stated there were care tasks listed in the computer for care staff to sign off on that they were completed; she added there was no follow-up completed by the RCC if tasks were not completed. Plan of Correction:• Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Resident #5: Her care plan has been updated to indicate frequency of toileting, as well as frequency of incontinence checks. Resident #10 is no longer a resident at the facility. • Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All current residents have the potential to be affected. • Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:The RCC and HSD will be educated on the need to ensure sufficient details are listed on the care plan in order for staff to provide appropriate care to residents. All direct care staff will be reeducated regarding the expectation that care is provided according to the care plan. All care providers and QMAPs shall demonstrate how to view the care plan in Point of Care. All direct care staff will be reeducated on the policy related to resident refusals of care, including documentation of all refusals, efforts taken, notifications made, and results. An audit will be conducted to ensure all current residents have had a functional assessment completed within the prior six months per facility policy. Any overdue functional assessment will be completed. Information from the functional assessment automatically flow to the care plan, so completion of functional assessments will ensure care plans are up to date. An audit will be conducted to ensure all residents who have experienced a change in status since their last functional assessment have had a change of condition functional assessment completed and their care plan accurately reflects assistance needed for activities of daily living. An audit will be conducted to ensure that all residents who are not independent with toileting have instructions on their car plan indicating the frequency for toileting and/or incontinence checks, including when awake and when sleeping. An audit will be conducted to ensure all residents have tasks entered in Point of Care to allow documentation of necessary care according to their care plan. Education will be done with all staff on the procedure to follow if a resident refuses any care; all refusals of care, efforts taken, and results will be documented in the medical record. • Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:The Resident Care Coordinator (RCC) will perform rounds weekly on all residents varying the time of day to ensure care needs are being met. Evidence of weekly rounds and findings and corrective action taken, if indicated, will be submitted to the administrator. Any reports of concerns related to resident care needs from any source will be reported to the RCC for investigation and corrective action. The concern, results of investigation, and any corrective action taken shall be documented on a concern form and submitted to the administrator. The Resident Care Coordinator (or designee) will perform audits for compliance of documentation entered in Point of Care at least weekly on-going with actions taken as indicated. Results of audits will be reported to the administrator weekly and to the facility QA committee on a monthly basis for at least three months or longer if indicated based on the results of the audits. Results of all of the above will be reviewed at the facility QA meeting on a monthly basis and further action taken as indicated. • Include dates when corrective action will be completed:12-24-23

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S D▼

Findings

Based on observation, record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one current resident (#4) and one former resident (#10) whose medications administration records (MARs) were reviewed. (Cross-reference Q1514)Specifically, a written practitioner's order, dated 9/12/23, directed the residence to administer morphine sulphate 100 mg/5 ml every four hours for pain to Resident #4. The residence failed to administer the medication on 9/13/23 at 6:00 p.m. because the medication was unavailable. A second practitioner's order, dated 9/13/23, directed the residence to administer morphine sulfate 100 mg/5 ml every two hours for pain to Resident #4. However, the residence did not administer the medication as ordered on 9/14/23 at midnight, 2:00 a.m. and 4:00 a.m. because the pharmacy removed the order from the residence's electronic medication administration record (eMAR). Per the residence's policy, only the pharmacy, not the residence staff, were authorized to enter medications on the eMAR. The health services director (HSD) acknowledged the order was valid because Resident #4's practitioner signed it, listing the correct medication, dosage, time, and route. As a result of the residence's failure, the resident experienced increased pain and aggression. Specifically, Former Resident #10 was admitted to the residence on 8/8/23. A written practitioner's order, dated 7/26/23, directed the residence to administer sertraline 100 mg one and one-half tablets once daily. However, the residence did not administer the medication from 8/8 until the evening of 8/10/23 because the orders were not entered into the eMAR. As a result of the residence's failure to administer the medication as ordered, on 8/11/23, Former Resident #10 had a change in baseline, developed tremors, and was sent to the emergency department for evaluation. Former Resident #10 was treated for tremors of the nervous system secondary to the lack of administration of sertraline for multiple days. This deficiency was cited previously during a licensure complaint survey on 12/14/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. References and Residence Policiesa. According to medlineplus.com, "Morphine is used to ensure effective pain management. Morphine may cause serious or life-threatening breathing problems, especially during the first 24 to 72 hours of your treatment and any time your dose is increased. Dose adjustments must be made by a physician and start low and gradually increase to treat and maintain effective pain control. Morphine must not be abruptly discontinued as it will result in withdrawal symptoms, including restlessness and more. Medication changes must be made by the prescribing physician. Take morphine exactly as directed." Medline (2023), retrieved from: https://medlineplus.gov/druginfo/meds/a682133.html.b. According to drugs.com, "sertraline is an antidepressant and is used to treat social anxiety disorder and depression. The medication should not be stopped without the practitioner's advice. Sertraline should be taken exactly as prescribed by the practitioner. "Do not stop using sertraline suddenly, or you could have unpleasant symptoms (such as agitation, confusion, tingling or electric shock feelings). Ask your doctor before stopping the medicine ... The most common side effects that may occur with abruptly stopping sertraline (Zoloft) may include: nausea, sweatingsevere mood changes, emotional lability, irritability, agitation, dizziness ... sensory disturbances ... tremor, anxiety, confusion ... insomnia (trouble sleeping), hypomania (abnormally high energy behavior) ... If you experience withdrawal symptoms, you are unlikely to have all, or even most, of these side effects ..." Drugs.com (2023), retrieved from: https://www.drugs.com/sertraline.html c. The residence's Medication Administration policy, dated 12/22, read, in part, "(Residence) ensures that each resident receives proper administration and monitoring of medications by complying with all federal and state laws and regulations related to the procurement, storage, administration of and disposal of medications. All medications shall be administered only with a physician's order. If an order cannot be followed, the physician will be notified.d. The residence's resident agreement, dated September 2022, read, "Staff will administer your medications as ordered by the physician." 2. Resident #4 was admitted to the residence on 9/8/23 with diagnoses including unspecified dementia, behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. a. Morphine Sulfate A written practitioner's order, dated 9/12/23, directed the residence to administer morphine sulfate 100 mg/5 ml every four hours for pain. However, the September 2023 MAR read the medication was not administered on 9/13/23 at 6:00 p.m. because the medication was not available, for a total of one dose missed. On 9/12/13 at 6:40 p.m., a progress note read, "Orders- Administration Note, Morphine Sulfate Waiting for pharmacy fill."b. Morphine Sulfate A written practitioner's order, dated 9/13/23, directed the residence to administer morphine sulfate 100 mg/5 ml every two hours for pain. However, the September 2023 MAR read the medication was not administered on 9/14/23 at midnight, 2:00 a.m., and 4:00 a.m. for three missed doses. A faxed pharmacy note, dated 9/13/23, at 1:33 p.m., read, "This is not a valid RX (prescription) order. If you are wanting us to fill it, please call/fax the pharmacy ASAP (as soon as possible)."On 9/14/23, a progress note by the HSD read, "Upon entering the unit, this writer heard resident crying out in pain and was advised that staff was providing 1:1 care to resident to maintain her safety. Staff advised this writer that all morphine had been discontinued and QMAP ... had attempted to contact pharmacy to understand why this occurred. This writer received from staff signed order for morphine provided to this facility on 9/13/2023, which was fixed on that date to (pharmacy). Staff stated multiple attempts including re-faxing and calling the after hours pharmacy line for assistance which up to this point had been unsuccessful. This writer called (pharmacy) after hours line at 06:01 and spoke (to a representative). She stated that she is not in the pharmacy, she also stated that (the pharmacy) had processed the order on 9/13/2023 and supplied the facility with new ordered morphine. This writer explained to (the representative) that all morphine orders were currently discontinued on the resident MAR and sought guidance on how to proceed. (The representative ) responded that what pharmacy opens at 08:00 pharmacy personnel could investigate. Call ended. This writer manually entered hospice morphine order dated from 9/13/2023 after speaking to pharmacy.b. ObservationsOn 9/13/23 at 8:30 a.m., while Staff #10 and Staff #3 provided transfer assistance to Resident #4, the resident yelled out. However, once the transfer was complete, Resident #4 stopped yelling. On 9/14/23 at approximately 7:20 a.m. Resident #4's loud screams could be heard from a distance of approximately 100 feet down the hallway. On 9/14/23 at 7:40 a.m. Resident #4 emitted screams as she attempted several times to sit on the side of the bed. She had thrown her legs off the bed and tried to get up or shift to a more comfortable position. The health services director (HSD) was unable to help the resident reach a comfortable state. c. InterviewsOn 9/14/23 at 7:25 a.m., the HSD stated that the pharmacy discontinued the morphine for Resident #4 after midnight on 9/13/23 because the pharmacy did not have a valid prescription. The HSD stated the pharmacy, not the residence staff, had removed the morphine medication from the eMAR; therefore, the resident care coordinator (RCC) did not administer Resident #4's medication ordered by the practitioner. She stated the residence policy was that only the pharmacy staff were authorized to enter medications on the electronic MAR, not the residence staff. The HSD acknowledged the order was valid because Resident #4's practitioner signed it, listing the correct medication, dosage, time, and route. She added that the RCC may not have administered the medication because the medication had "fallen off the electronic MAR." The HSD acknowledged this gap in medication caused Resident #4 pain. On 9/14/23 at approximately 8:30 a.m., Resident #4's family member stated Resident #4's health had declined in the past few days; he added the residence had difficulty controlling her pain and aggression. He added that the residence did not call to inform him the residence had failed to administer morphine medication as ordered. On 9/14/23 at approximately 9:30 a.m., the external hospice nurse stated she was not informed that the residence failed to administer medication to Resident #4. She stated that a missed dose of morphine medication would increase pain, and the residence should have notified her when they noticed the medication was not on the MAR. She added that Resident #4 had one of the worst cases of terminal aggression she had seen. 3. Former Resident #10 was admitted to the residence on 8/8/23 with diagnoses including depression, constipation, hypertension, type two diabetes, gastro-esophageal reflux disease, and dementia. a. Sertraline A written practitioner's order, dated 7/26/23, directed the residence to administer sertraline 100 mg; one and one-half tablets once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered on 8/8 or 8/9/23 for a total of two missed doses. A practitioner progress note, dated 7/26/23, read Former Resident #10 had increased anxiety if he missed his sertraline. An admission assessment, dated 8/9/23 for Former Resident #10 read he was independent with ambulation and had a steady gait. The assessment did not indicate Former Resident #10 experienced anxiety or was up throughout the night. Progress notes for August 2023 in the record for Former Resident #10 revealed the following:On 8/9/23, Former Resident #10 was anxious throughout the shift and difficult to redirect. On 8/10/23, Former Resident #10 was difficult to redirect and was up all throughout the night. On 8/11/23 at 6L40 a.m. Former Resident #10 was seated naked on the floor in front of his bed. Onb 811/23 at 8:22 p.m. Former Resident #10 was sent out to the hospital for shaking and back pain. Former Resident #10 came back around 1:00 a.m., "still having tremors. Possible withdrawal from missing meds for (sic) couple of days."A practitioner progress note, dated 8/11/23, read Former Resident #10 was evaluated in the emergency room for tremors of the nervous system. "I discussed this case with (sic) pharmacy, they state that the patient has not been getting his sertraline, he did not receive it ... In light of this I suspect the (Former Resident #10) symptoms are likely secondary to sertraline withdrawal. (Former Resident #10) to be restarted on sertraline ... As discussed above, I suspect that the etiology for the patient's symptoms is withdrawal from sertraline considering the several days that he did not receive it ..."On 9/13/23 at 2:06 p.m., the HSD said the residence had not administered Former Resident #10's medications from 8/8/23 until the evening of 8/10/23. On 9/14/23 at 9:50 a.m., the administrator said the residence had not administered Former Resident #10's medications for two days following his admission to the residence on 8/8/23.b. Polyethylene Glycol A written practitioner's order, dated 7/26/23, directed the residence to administer polyethylene glycol 17 g once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered on 8/9 and 8/10/23.c. MetforminA written practitioner's order, dated 7/26/23, directed the residence to administer metformin 1,000 mg once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered 8/9 and 8/10/23. d. LosartanA written practitioner's order, dated 7/26/23, directed the residence to administer losartan 50 mg once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered on 8/9 and 8/10/23.e. Finasteride A written practitioner's order, dated 7/26/23, directed the residence to administer finasteride 5 mg once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered on 8/8 and 8/9/23.f. AmlodipineA written practitioner's order, dated 7/26/23, directed the residence to administer amlodipine 5 mg once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered on 8/8 and 8/9/23. On 9/14/23 at approximately 11:30 a.m., the administrator said she expected the medications to be in the building prior to a resident moving in. She added if there were no orders in the MAR system the resident should not move in. The administrator said she expected the HSD to enter the medications into the MAR system immediately so a resident does not go without being administered their medication. On 9/14/23 at approximately 11:30 a.m., the administrator said the reason the deficiency was recited was because the medication process was not organized correctly.

Plan of correction · submitted by the facility

Tag 1468: S/S: D Medication and Medication Administration- Orders (page 23)- Requirement: Facility shall be responsible for complying with practitioner orders associated with medication administration. Failed to comply with practitioner orders for resident #4 and resident #10. Resident #4: Didn’t get MSO4 on 9/13/23 at 18:00 because med not availableDidn’t get MSO4 on 9/14/23 at midnight, 02:00, and 04:00 because medication did not show up on the eMARPharmacy had entered the order on their end, but facility didn’t see itFacility thought pharmacy had DCd the orderThe facility had an order and did not enter it into the computer so staff could give itResident experienced increased pain and aggressionFormer resident #10: Admitted 8/8/23 and didn’t get sertraline 100mg 1.5 tablets daily from 8/8 until eve of 8/10/23 because orders were not entered into eMARPractitioner notes dated 7/26/23 stated if resident did not get sertraline, would experience increased anxietyPN 8/9-8/11: showed increased anxiety, difficult to direct, naked on the floor in front of his bed, sent to the hospital for shaking and back pain, had tremors; practitioner evaluation and felt could have been attributed to not getting sertralineAlso did not get metformin, losartan, finasteride, and amlodipineAdministrator stated meds should be in the facility prior to resident moving in; if don’t have meds, should not move inPlan of Correction: • Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Resident #4 and resident #10 no longer reside in the facility.• Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All current and future residents have the potential to be affected.• Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:Investigation of resident #4 situation revealed a failure occurred between the pharmacy interface and PointClickCare (PCC), so the order was not visible on the eMAR for facility staff to administer the medication. The following systemic change will be implemented:The facility Health Services Director, Resident Care Coordinator, and QMAPs will be educated to view order messages in PCC to identify if a failure has occurred if they receive an order confirmation or a medication from the pharmacy and the order is not visible in eMAR.Staff will be educated to notify the Health Services Director if an order needs to be entered manually into PCC. A triple check process will be used when an order has been entered manually to ensure the order was entered correctly prior to administration. Staff will be educated on pain management for residents, including the need to call a provider if the resident is experiencing uncontrolled pain symptoms or pain medication is unable to be administered. Staff will be educated to document all efforts for pain management, including notification of providers and POA, in the medical record. Investigation of resident #10 situation concluded that the resident was admitted to the facility without current signed orders from the medical provider and orders were unable to be obtained in a timely manner, thus causing a delay in obtaining medications. The following systemic change has been implemented:Admissions staff have been educated that current signed orders must be received prior to the resident admitting to the facility. Admissions will educate the POA that medications are delivered in the evening by the pharmacy, so medications due prior to that should be administered by the family on the day of admission. Orders will be reviewed by the nurse to determine if clarification needs to be obtained on any orders prior to faxing them to pharmacy. The pharmacy shall be called to ensure receipt of admission orders and to promptly identify any concerns with the orders. The nurse will communicate final acceptance of the orders to the admissions department and an admission time will be finalized. The Health Services Director and QMAPs will watch for order confirmation via fax from the pharmacy that all orders have been confirmed and will verify orders in eMAR. This will be completed during business hours to ensure all medications will arrive in the medication delivery that evening. Staff will be reeducated on the policy, “Medication Administration“. All actions taken to administer medications shall be documented in the resident’s medical record, including if a resident refuses, a medication is unavailable, or there are any other issues related medication administration.• Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:Information will be added to nurse, RCC, and QMAP orientation and training to ensure all new staff are educated. (add to training checklist and include information in QMAP reference book)In morning meeting Monday-Friday, the Health Services Director and/or Resident Care Coordinator will review refused medications and missed medications to ensure appropriate follow-up was done per the policy and information was documented in the medical record. This will be done on an on-going basis. Each Monday or in the event of a holiday, the reports will be run for days since the prior morning meeting. The process for resident #10 will be added to the admission checklists for admissions, the nurse, and QMAPs. For all new admissions, the administrator ensure a resident does not move into the facility until orders have been approved by the pharmacy and it has been confirmed that the orders are being processed for delivery that day. • Include dates when corrective action will be completed:Completion Date will be by 12/24/23.

9999Final ObservationsSurveyor note▼

Findings

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Plan of correction

The state did not require a plan of correction for this citation.

9/13/2023Licensure Complaint · ID KT2Q119 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO33495, #CO33552, #CO33567, was completed on 9/14/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0634Prsnnl-Ablty Prfrm Job Fnctns P/P TB/RstrctnS/S B▼

Findings

Based on observation, record review and interview, the residence failed to ensure that five of five sample staff (#3, #7-#10) completed a tuberculin skin test prior to direct contact with residents, affecting 29 current residents. Findings include 1. Reference and Residence Policiesa. According to the Centers for Disease Control and Prevention (CDC), "All United States (U.S.) health care personnel should be screened for tuberculosis (TB) upon hire (i.e., preplacement)." Centers for Disease Control and Prevention (CDC) (2022) TB Screening and Testing of Health Care Personnel, retrieved from: https://www.cdc.gov/tb/topic/testing/healthcareworkers.htmb. The residence's new employee checklist, dated 6/15/22, read: "Prior to job offer: Completed job application ... TB Test" c. The residence's Employee Tuberculosis Screening and Testing policy, dated 3/21/18, read, in part, "At the time of hire, all new employees and volunteers will be screened for TB, which includes a TB risk assessment, a TB symptom screen and a TB test."2. Record reviewOn 9/13/23, the personnel files for Staff #3, #7-#10 did not contain the results of a pre-employment tuberculosis screening. 3. ObservationsOn 9/13/23 at 7:25 a.m., Staff #7 was observed providing care and services to residents. On 9/13/23 at 8:30 a.m., Staff #10 and Staff #3 were observed providing care and services to Resident #4. On 9/13/23 at 9:29 a.m., Staff # 9 was observed providing care and services to residents. 4. InterviewsOn 9/13/23 at 7:52 a.m. Staff #8 said she had not been tested for TB before contact with residents. On 9/13/23 at 7:52 a.m. Staff #9 said she had not been tested for TB before contact with residents. On 9/13/23 at 7:52 a.m. Staff #10 said she had not been tested for TB before contact with residents. On 9/13/23 at approximately 12:30 p.m., health services director (HSD) acknowledged staff (#3, #7-10) had not been tested for TB before hire. She stated she knew there was a two-step process for TB testing. On 9/14/23 at 11:36 a.m., the administrator acknowledged that Staff #3, #7-#10 still had not completed TB skin tests.

Plan of correction · submitted by the facility

Tag Q634: S/S: B Personal Ability Perform Job Functions P/P TB/Restriction (page 2) Requirement: Must have written policies concerning pre-employment physical evaluations and employee health, including:TB skin testing for each staff member and volunteer prior to direct contact with residentsImposition of work restrictions on direct care staff who are known to be affected with any illness in a communicable stage. At a minimum, such staff shall be barred from direct contact with residents or resident food. Failed to ensure 5 staff completed TB skin test (#3, #7-0#10). Plan of Correction:• Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Sample Staff #3, #7, #10 have all received their TB tests. • Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All current residents have the potential to be affectedAn audit of all current employees will be conducted to determine those who did not have TB skin testing or contraindication/alternate testing performed upon hire• Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:All current employees who have not completed TB skin testing (or had contraindication/alternate testing) will be screened for TB and will receive a two-step TB skin test unless contraindicated. A new policy was developed related to TB screening for all new hiresA new policy was developed related to employee illness or infection and restrictions for contact with residents. • Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:All employees will be trained on the two new policies. A new employee checklist will be developed listing all required items that are needed to be completed upon hire and will include TB screening, which includes completion of a TB risk assessment, a TB symptom scree, and a Mantoux tuberculin skin test unless contraindicated. The checklist will delineate items that must be completed PRIOR to direct contact with residents. Direct care staff will not be allowed to have direct contact with residents until all required elements have been completed. The Business Office Coordinator will ensure completion of all items on the new employee checklist for new hires, including completion of TB screening. The Business Office Coordinator will ensure complete documentation of TB screening is included in the employee’s personnel file. Incomplete personnel files will be filed separately from complete personnel files. Once all required new employee items are documented in the employee file, the file will be moved to the location with other completed files. The administrator will meet monthly with the Business Office Coordinator to review all incomplete employee files. • Include dates when corrective action will be completed:New policies and associated forms for TB process were completed 10/27/23Employee education on new policies completed by 12-24-23Audit of employees needing to be screened for TB and have TB skin test completed by 12-24-23TB skin tests completed by 12-24-23New employee checklist completed by 12-24-23

0810P/P Dvlp/Anul RvwS/S B▼

Findings

Based on record review and interview, the residence failed to develop policies and procedures regarding staff training, affecting 29 residents. Findings include:On 9/14/23 at approximately between 7:30 a.m. and 11:00 a.m., the residence's staff training policy was requested. However, no such policy was provided. On 9/14/23 at 11:36 a.m., the administrator said the residence did not have a policy regarding staff training. She added she was aware one was required.

Plan of correction · submitted by the facility

Tag Q810: S/S: B Policy and Procedure Annual Review (page 4)Requirement: Must develop and at least annually review all policies and procedures.. lists required P&P….Failed to develop P&P regarding staff training. Staff training policy was requested and none was provided. Administrator said the residence did not have a policy regarding staff training. Plan of Correction:• Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:The 29 affected residents who were affected by this deficiency will be remedied by the revision of the staff training policy.• Address how the facility will identify other residents having the potential to be affected by the same deficient practice:The training policy development and implementation will ensure that all residents are cared for by well trained staff. All residents have the potential to be affected. • Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: A training policy will be reviewed and implemented with all staff to ensure proper training. All policies will be reviewed annually to ensure for completeness and accuracy at the QAPI committee meeting.• Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: At the monthly QAPI meeting tracking and trending of the training will be presented and modified as needed to ensure that all staff are properly trained relative to caring for the residents. The annual policy review will be done by the QAOI committee annually.• Include dates when corrective action will be completed: 12-24-23

1110Res Care Srvs-Min Srvs Res AgrS/S A▼

Findings

Plan of correction · submitted by the facility

1316Res Rghts Rghts/Rspn-Choice/Invlv Care/SvcsS/S A▼

Findings

Based on interview and record review, the residence failed to ensure that residents rights included the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence, affecting one of two sample residents (#7) and one former resident (#10). Findings include:1. Residence PolicyThe residence's undated posted resident rights read, in part, "The right to expect the cooperation of the facility in achieving the maximum degree of benefit from those services which are made available by the facility."2. Resident #7 was admitted to the residence on 12/10/19. An assessment for Resident #7, dated 5/26/23, read she required assistance with toileting. The call light response for August and September 2023 revealed Resident #7 utilized her call light to summon staff assistance and waited longer than 15 minutes for staff assistance on:8/1/23: one hour and 27 minutes8/2/23: one hour and 14 minutes8/4/23: 43 minutes8/7/23: two hours and nine minutes8/8/23: 47 minutes8/12/23: 48 minutes 8/21/23: 57 minutes8/24/23: 53 minutes 8/26/23: 51 minutes 8/28/23: 46 minutes8/30/23: two hours and 32 minutes8/31/23: three hours and 25 minutes9/4/23: 33 minutes9/5/23: 28 minutes9/7/23: 40 minutes9/8/23: 41 minutes9/12/23: 57 minutesOn 9/14/23 at 10:23 a.m., a family member of Resident #7 said Resident #7 was not mobile at all and had to wait over an hour for staff assistance to get dressed and use the bathroom recently. She added, she was worried about the delay in staff response to the resident's request for assistance. 3. Former Resident #10 was admitted on 8/8/23. There was an undated RN (registered nurse) comprehensive initial assessment in the record for Former Resident #10 that read Former Resident #10 required staff to demonstrate teeth brushing and he needed cues from staff when he dressed and undressed for the day. There was no task listed for assistance with showering. A care plan in the record for Former Resident #10, dated 8/9/23, read Former Resident #10 needed assistance with teeth brushing and showers. The call light response for August 2023 revealed Former Resident #10 utilized his call light to summon staff assistance and waited longer than 15 minutes for staff assistance on:8/16/23: two hours and 55 minutes8/18/23: 54 minutesA document written by a family member of Former Resident #10, dated 8/31/23 read, "On August 18th, (family member) pressed the patient alarm button (call light) in (Former Resident #10's) room to get some assistance and no one came. About two hours later the Qmap (qualified medication administration person) on duty came in and said (Former Resident #10's) alarm keeps going off and walked over to the alarm and turned it off." On 9/14/23 at approximately 11:30 a.m., the administrator said she expected staff to respond to residents immediately or within a couple of minutes when residents pushed their pendants or pulled cords for assistance. The administrator stated the residence was not currently reviewing lengthy response times.

Plan of correction · submitted by the facility

Tag Q1316: S/S: A Resident Rights and Responsibilities- Choice and involvement in Care and Services (page 11)Requirement: Resident Rights: facility shall observe resident rights in the care, treatment, and oversight of residents… lists resident rights. Failed to ensure that resident rights included the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the ALR affecting one of two sample residents, (#7) and one former resident (#10). Resident #7: Call light response times are listed and were greater than 15 minutes- longest was three hours and 25 minutes… many 30 minutes to one hourPer family member, resident is not mobile and had to wait for over an hour to get dressed and use bathroomFormer resident #10: Undated RN comprehensive initial assessment stated staff to demonstrate teeth brushing and he needed cues from staff when he dressed and undressed; there was no task listed to assist with showering; Care plan dated 8/9/23 stated he needed assistance with teeth brushing and showersCall light response for this resident (greater than 15 mintues): On 8/16/23 waiting 2 hours and 55 min and on 8/18/23 waited 54 minutesOn 8/18/23, family member pressed pendant (call light) in room to get assistance and no one came; about two hours later the QMAP on duty came in and said his alarm keeps going off and walked over to the alarm and turned it offAdministrator said the facility was not currently reviewing call light response times and she expected staff to respond to residents immediately or within a couple of minutes. Plan of Correction:• Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Resident #7: Will verify call light is functioning properly(see plan below for all residents)Review call light response logs on a daily basis (Mon-Fri) and investigate any call light response longer than 15 minutesResident #10: No longer at the facility• Address how the facility will identify other residents having the potential to be affected by the same deficient practice:Facility will run a call light response report to determine all residents who are currently using a call light. This call light response will be reviewed daily at the stand-up meeting.• Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:Staff will round on a routine basis for all residents and provide care in a manner so care needs are anticipated, thus decreasing the need for residents to use their call light to the extent possible. Facility will purchase additional pagers so all care providers and QMAPs wear pagers; Pagers will be with each care provider and QMAP at all times while on duty. The QMAP pager will not be on or in the medication cart. The Resident Care Coordinator shall also carry a pager at all times. All staff are responsible for responding to call lights. Call lights response is a priority when providing care. All call lights shall be answered as soon as possible, with a goal of answering all lights within 10 minutes. Call lights shall not be turned off until the need has been met. Staff shall not turn off the light and say, “I’ll be back.“ Staff shall use walkie-talkies to communicate with each other regarding who is answering the light when a pager indicates a call light has been activated to ensure someone is answering it in a timely manner. The QMAP assigned to the resident shall ensure that someone is answering the light timely.• Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:The facility will purchase enough pagers to ensure all direct care staff on duty are carrying a pager. The facility will develop a process for signing pagers in and out at shift change. The on-coming QMAP on each shift will be responsible to ensure all staff from the prior shift have turned in their pagers and all staff on the on-coming shift have been assigned a pager. This information will be documented on the pager sign in/out logEducation will be provided to all direct care staff to include:Process for checking in and out pagers at shift change. Expectations for carrying a pager and walkie-talkie. Expectation for communicating who is responding to the call light when one is activated and the responsibility of the QMAP to ensure the light is answered. How to correctly use the pager with return demonstration by each direct caregiver; Documentation of education and return demonstration shall be kept in their employee fileImportance of routine rounds and anticipating the needs of residents to prevent the need for them to use their call lightAudit process, so staff understand the call light response log will be run daily Mon-Fri with an investigation of all call lights lasting longer than 15 minutes. Documentation will be made of all education and kept in each employee's file. Education shall be added to new employee orientation and included on the new employee orientation checklist for all applicable staff. The Resident Care Coordinator shall monitor the pager check in/out process and to do spot checks to ensure staff on duty are wearing pagers. Audits. Facility will run the call light response log and review it in morning stand-up daily Mon-Fri on an ongoing basis. Facility will investigate all call light responses longer than 15 minutes to determine root cause and implement appropriate corrective action. Facility will track and trend call light response times on a monthly basis in facility QA meetings ongoing, to include the number of call lights longer than 15 minutes by unit, time of day/shift, and QMAP in charge at the time; Corrective action will be determined based on trends and results of investigation• Include dates when corrective action will be completed:Pagers to be available by: 12-24-23. Staff education to be completed by: 12-24-23. Call light response reports to be run each morning meeting beginning: 12-1-23. The call light response audit will be brought to the monthly QAPI committee meeting for tracking and trending. The ongoing process will be implemented by 12-24-23

1362Res Rts-Inv Ab/Neg Alleg or Inj Unk Org IUOS/S B▼

Findings

Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting one former resident (#10). Findings include:Former Resident #10 was admitted to the residence on 8/8/23. A progress note in the record for Former Resident #10, dated 8/24/23 read, in part, "L (left) arm above/on side of elbow is a bruise. We are not sure how it got their (sic) ..." A progress note in the record for Former Resident #10, dated 8/25/23 read, in part, "At around 9a (9:00 a.m.) tried to help (Former Resident #10) sit in a chair. Noticed that he was not standing up all the way and was limping on his right foot not wanting to bear weight ... Around 11amish (11:00 a.m.) (family member) came and chose to send him out to the hospital."There was no evidence in the record for Former Resident #10 that the residence conducted an investigation on or after 8/24/23. On 9/14/23 at 9:22 a.m., the health services director said she would have been the one to complete the investigation and did not recall having completed an investigation, as required. She added she was unsure if the family was notified of the bruise. On 9/14/23 at approximately 11:30 a.m., the administrator said she was aware the residence was required to have a policy on investigations of injuries with known or unknown origin. The administrator acknowledged only an incident report was completed for the bruise noticed on Former Resident #10 and not an investigation, as required.

Plan of correction · submitted by the facility

Tag 1362: S/S: B Resident Rights- Investigation of Abuse and Neglect Allegation or Injuries of Unknown Origin (page 15)Requirement: Facility shall develop and implement P&P for identification, reporting, and investigation of injuries of unknown origin. Shall include….(lists on page 16)… Failed develop and implement P&P affecting one former resident (#10) who was admitted on 8/8/23. PN dated 8/24/23 read, in part, “L (left) arm above/on side of elbow is a bruise. We are not sure how it got there…“PN dated 8/25/23 states he was not standing up all the way and limping on his right foot and not wanting to bear weight… family member came and chose to send him out to the hospitalNo evidence in the record that the facility conducted an investigation on or after 8/24/23On 9/14/23 HSD said she would have been the one to complete the investigation and did not recall having completed an investigation, as required. She was unsure if the family was notified of the bruise. Administrator acknowledged only an incident report was completed for the bruise and no investigation was completed Plan of Correction: • Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Resident #10 is no longer a resident at the facility.• Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All current residents have the potential to be affected. • Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:The Health Services Director and Administrator employed at the time of this incident no longer works at the facility. The current Health Services Director and Administrator have been educated on the need to investigate all injuries of unknown origin to rule out potential abuse and neglect and to document results of the investigation in the resident’s medical record. • Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:The corporate nurse consultant will audit monthly for at least 3 months and at least quarterly ongoing for all injuries of unknown origin to determine if an investigation was conducted, the results of the investigation, and to ensure appropriate documentation was included in the resident’s medical record. Results of the audits will be submitted to the facility Administrator.• Include dates when corrective action will be completed:Education with the Health Services Director and Administrator was completed on 11/17/23 by the corporate nurse consultant. Audits will begin in December 2023 by the corporate nurse consultant.

1428Med/Med Adm-Gen Rq QMAP Srvs w/in ScopeS/S A▼

Findings

Based on observation, record review and interview, the residence failed to ensure qualified medication administration persons (QMAPs) were not permitted to mask administration of medication, affecting one sample resident (#9). Findings include:1. Reference and Residence Policies a. Chapter VII regulations governing assisted living residences, part 2.26, defines "Medication administration" as assisting a person in the ingestion, application, inhalation, or, using universal precautions, rectal or vaginal insertion of medication, including prescription drugs, according to the legibly written or printed directions of the attending physician or other authorized practitioner, or as written on the prescription label, and making a written record thereof with regard to each medication administered, including the time and the amount taken.(B) Medication administration by a qualified medication administration person (QMAP) does not include judgment, evaluation, assessments, or injecting medication (unless otherwise authorized by law in response to an emergent situation.)b. The residence's Medication Administration policy, dated 12/22, read, "The Health Services Director shall provide ongoing supervision of personnel administering medications, including regular observation of performance in actual preparation and administration of medications."c. The residence's Medication Administration policy, dated 12/22, read, "If a resident initially refuses a medication, at least 2 (two) more attempts shall be made to administer the medication using behavioral strategies to try to increase compliance; If a resident still refuses after 3 attempts, documentation shall include the reason(s) for the refusals and strategies tried, which may include, but are not limited to: a. Providing distraction, waiting a period of time, then trying again b. Waiting a period, then administering in a different and calm location c. Ask another QMAP or nurse to try to administer the medication. d. Seeking assistance from family or another staff member, the resident may respond better to e. Giving the resident something to hold as a distraction. f. Providing a written card stating their physician or family member said they should take their medication." 2. ObservationsOn 9/13//23 at approximately 9:40 a.m., Staff #9 prepared medications for Resident #9 which included polyethylene glycol. The medication was listed on the medication administration record for Resident #9. Staff #9 went to the Resident #9 and asked Resident #9, "Do you want some coffee?" Resident #9 said, "Yes." During preparation of the medication, Staff #9 set the coffee on the medication cart. She opened the polyethylene glycol powder and poured the medication into Resident #9's coffee and used a spoon to stir the medication into the coffee until it dissolved. Staff #9 then handed the coffee with the crushed medications to Resident #9. Staff #9 did not inform the resident the resident's medications were in the coffee. On 9/13//23 at 9:40 a.m., Staff #9 crushed medication for Resident #9 and added the medication to canned fruit with juice out of the resident's line of sight. Staff #9 handed the fruit with the medications mixed inside to Resident #9. Staff #9 did not inform the resident that the resident's medications were in the syrup under the fruit. 3. Record ReviewResident #9 was admitted to the residence on 10/7/21 with a diagnosis of unspecified dementia, psychotic disturbance, and anxiety. 4. InterviewsOn 9/13/23 at 8:17 a.m., Staff #9 stated that Resident #9 had always spit out her medications if staff informed her that crushed medications were being administered. Staff #9 was taught by Staff #11 to hide the meds in her food. Further, Staff #9 stated that Resident #9's behaviors increased if she did not take her medications. Staff #9 said the family knew they were masking medications to ensure the resident would receive them. On 9/13/23 at approximately 9:30 a.m., Staff #9 stated shehad been trained by Staff #8 and the resident care coordinator (RCC) to place the crushed or open time-release pills for Resident # 9 into syrup from canned fruit and then layer fruit on top. Staff #9 stated on occasion, Resident #9 commented that the fruit tasted bad when medication was added but ate it anyway. On 9/13/23 at 9:35 a.m. Staff #8 stated the external hospice agency staff was aware the residence staff hid Resident #9's medications in fruit syrup and administered to Resident #9. She added Resident #9 refused her medications when told they were medications. On 9/14/23 at 12:25 p.m., the health services director stated that Resident #9 had a crush order; however, staff were required to identify the medication when they added it to the resident's drink or food. She added she was made aware that staff were not identifying the medication on the date of the onsite visit. On 9/14/23 at 9:28 a.m., the administrator stated all QMAPS should identify that medications were being administered even if the medications were crushed.

Plan of correction · submitted by the facility

Tag 1428: S/S: A Medication and Medication Administration Requirement: Facility shall not permit a QMAPS to perform any of the following (lists page 19)… includes masking or deceiving administration of medication including, but not limited to, concealing in food or liquid. Failed to ensure QMAPs were not permitted to mask administration of medication affecting one sample resident (#9). Medication Administration policy dated 12/22… HSD shall provide ongoing supervision of personnel administering meds… regular observation of performance in actual preparation and administration of medicationsStates what to do if a resident refuses a med… lists….Observations:On 9/13/23 at 09:40, staff #9 prepared meds, which included polyethylene glycol (Miralax). She asked the resident if she wanted coffee and had poured the Miralax in the coffee. She did not inform the resident the Miralax was in the coffeeOn 9/13/23 at 09:40, staff #9 crushed a medication and added it to canned fruit with the juice out of the resident’s line of sight; did not inform the resident that the medication was in the syrup under the fruit. InterviewsStaff member said resident had always spit out her meds and had been trained to hide meds in her food otherwise she would not take her meds; said the family knew they were masking meds to ensure resident would receive them; said hospice was also awareStaff stated on occasion resident would comment the fruit tasted bad when med was added but ate it anywayHSD and administrator stated staff were to state what meds were being administered Plan of Correction:• Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:The affected resident no longer resides at the facility.• Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All residents have the potential to be affected. • Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:The Medication Administration Policy was updated to include, “Medications shall not be masked or administered without a resident’s knowledge. If medications are placed in food or liquid for ease of administration, the resident shall be made aware the food or beverage contains the medication.“All Nurses and QMAPs will be educated on the revised Medication Administration Policy. Training with staff will include behavioral strategies on medication administration with dementia residents. Staff will be instructed to report difficulties to the Health Services Director and/or Resident Services Director for further assistance if the strategies are not successful.• Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:The Health Services Director or Resident Care Coordinator will monitor medication administration of at least 2 sample residents who take their medication in food or beverages at least twice monthly for at least three months to ensure the QMAP is explaining to the resident what medications are in the food/beverage they are receiving. Results of the audits will be reported to the facility QAPI meeting monthly for at least three months and longer if indicated. • Include dates when corrective action will be completed:All corrective action will be completed by December 24th.

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S D▼

Findings

Based on observation, record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one current resident (#4) and one former resident (#10) whose medications administration records (MARs) were reviewed. (Cross-reference Q1514)Specifically, a written practitioner's order, dated 9/12/23, directed the residence to administer morphine sulphate 100 mg/5 ml every four hours for pain to Resident #4. The residence failed to administer the medication on 9/13/23 at 6:00 p.m. because the medication was unavailable. A second practitioner's order, dated 9/13/23, directed the residence to administer morphine sulfate 100 mg/5 ml every two hours for pain to Resident #4. However, the residence did not administer the medication as ordered on 9/14/23 at midnight, 2:00 a.m. and 4:00 a.m. because the pharmacy removed the order from the residence's electronic medication administration record (eMAR). Per the residence's policy, only the pharmacy, not the residence staff, were authorized to enter medications on the eMAR. The health services director (HSD) acknowledged the order was valid because Resident #4's practitioner signed it, listing the correct medication, dosage, time, and route. As a result of the residence's failure, the resident experienced increased pain and aggression. As a result of the residence's failure to administer the medication as ordered, the resident experienced increased pain and aggression. Specifically, Former Resident #10 was admitted to the residence on 8/8/23. A written practitioner's order, dated 7/26/23, directed the residence to administer sertraline 100 mg one and one-half tablets once daily. However, the residence did not administer the medication from 8/8 until the evening of 8/10/23 because the orders were not entered into the eMAR. As a result of the residence's failure to administer the medication as ordered, on 8/11/23, Former Resident #10 had a change in baseline, developed tremors, and was sent to the emergency department for evaluation. Former Resident #10 was treated for tremors of the nervous system secondary to the lack of administration of sertraline for multiple days. Findings include:1. References and Residence Policiesa. According to medlineplus.com, "Morphine is used to ensure effective pain management. Morphine may cause serious or life-threatening breathing problems, especially during the first 24 to 72 hours of your treatment and any time your dose is increased. Dose adjustments must be made by a physician and start low and gradually increase to treat and maintain effective pain control. Morphine must not be abruptly discontinued as it will result in withdrawal symptoms, including restlessness and more. Medication changes must be made by the prescribing physician. Take morphine exactly as directed." Medline (2023), retrieved from: https://medlineplus.gov/druginfo/meds/a682133.html.b. According to drugs.com, "sertraline is an antidepressant and is used to treat social anxiety disorder and depression. The medication should not be stopped without the practitioner's advice. Sertraline should be taken exactly as prescribed by the practitioner. "Do not stop using sertraline suddenly, or you could have unpleasant symptoms (such as agitation, confusion, tingling or electric shock feelings). Ask your doctor before stopping the medicine ... The most common side effects that may occur with abruptly stopping sertraline (Zoloft) may include: nausea, sweatingsevere mood changes, emotional lability, irritability, agitation, dizziness ... sensory disturbances ... tremor, anxiety, confusion ... insomnia (trouble sleeping), hypomania (abnormally high energy behavior) ... If you experience withdrawal symptoms, you are unlikely to have all, or even most, of these side effects ..." Drugs.com (2023), retrieved from: https://www.drugs.com/sertraline.html c. The residence's Medication Administration policy, dated 12/22, read, in part, "(Residence) ensures that each resident receives proper administration and monitoring of medications by complying with all federal and state laws and regulations related to the procurement, storage, administration of and disposal of medications. All medications shall be administered only with a physician's order. If an order cannot be followed, the physician will be notified.d. The residence's resident agreement, dated September 2022, read, "Staff will administer your medications as ordered by the physician." 2. Resident #4 was admitted to the residence on 9/8/23 with diagnoses including unspecified dementia, behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. a. Morphine Sulfate A written practitioner's order, dated 9/12/23, directed the residence to administer morphine sulfate 100 mg/5 ml every four hours for pain. However, the September 2023 MAR read the medication was not administered on 9/13/23 at 6:00 p.m. because the medication was not available, for a total of one dose missed. On 9/12/13 at 6:40 p.m., a progress note read, "Orders- Administration Note, Morphine Sulfate Waiting for pharmacy fill."b. Morphine Sulfate A written practitioner's order, dated 9/13/23, directed the residence to administer morphine sulfate 100 mg/5 ml every two hours for pain. However, the September 2023 MAR read the medication was not administered on 9/14/23 at midnight, 2:00 a.m., and 4:00 a.m. for three missed doses. A faxed pharmacy note, dated 9/13/23, at 1:33 p.m., read, "This is not a valid RX (prescription) order. If you are wanting us to fill it, please call/fax the pharmacy ASAP (as soon as possible)."On 9/14/23, a progress note by the HSD read, "Upon entering the unit, this writer heard resident crying out in pain and was advised that staff was providing 1:1 care to resident to maintain her safety. Staff advised this writer that all morphine had been discontinued and QMAP ... had attempted to contact pharmacy to understand why this occurred. This writer received from staff signed order for morphine provided to this facility on 9/13/2023, which was fixed on that date to (pharmacy). Staff stated multiple attempts including re-faxing and calling the after hours pharmacy line for assistance which up to this point had been unsuccessful. This writer called (pharmacy) after hours line at 06:01 and spoke (to a representative). She stated that she is not in the pharmacy, she also stated that (the pharmacy) had processed the order on 9/13/2023 and supplied the facility with new ordered morphine. This writer explained to (the representative) that all morphine orders were currently discontinued on the resident MAR and sought guidance on how to proceed. (The representative ) responded that what pharmacy opens at 08:00 pharmacy personnel could investigate. Call ended. This writer manually entered hospice morphine order dated from 9/13/2023 after speaking to pharmacy.b. ObservationsOn 9/13/23 at 8:30 a.m., while Staff #10 and Staff #3 provided transfer assistance to Resident #4, the resident yelled out. However, once the transfer was complete, Resident #4 stopped yelling. On 9/14/23 at approximately 7:20 a.m. Resident #4's loud screams could be heard from a distance of approximately 100 feet down the hallway. On 9/14/23 at 7:40 a.m. Resident #4 emitted screams as she attempted several times to sit on the side of the bed. She had thrown her legs off the bed and tried to get up or shift to a more comfortable position. The health services director (HSD) was unable to help the resident reach a comfortable state. c. InterviewsOn 9/14/23 at 7:25 a.m., the HSD stated that the pharmacy discontinued the morphine for Resident #4 after midnight on 9/13/23 because the pharmacy did not have a valid prescription. The HSD stated the pharmacy, not the residence staff, had removed the morphine medication from the eMAR;therefore, the resident care coordinator (RCC) did not administer Resident #4's medication ordered by the practitioner. She stated the residence policy was that only the pharmacy staff were authorized to enter medications on the electronic MAR, not the residence staff. The HSD acknowledged the order was valid because Resident #4's practitioner signed it, listing the correct medication, dosage, time, and route. She added that the RCC may not have administered the medication because the medication had "fallen off the electronic MAR." The HSD acknowledged this gap in medication caused Resident #4 pain. On 9/14/23 at approximately 8:30 a.m., Resident #4's family member stated Resident #4's health had declined in the past few days; he added the residence had difficulty controlling her pain and aggression. He added that the residence did not call to inform him the residence had failed to administer morphine medication as ordered. On 9/14/23 at approximately 9:30 a.m., the external hospice nurse stated she was not informed that the residence failed to administer medication to Resident #4. She stated that a missed dose of morphine medication would increase pain, and the residence should have notified her when they noticed the medication was not on the MAR. She added that Resident #4 had one of the worst cases of terminal aggression she had seen. 3. Former Resident #10 was admitted to the residence on 8/8/23 with diagnoses including depression, constipation, hypertension, type two diabetes, gastro-esophageal reflux disease, and dementia. a. Sertraline A written practitioner's order, dated 7/26/23, directed the residence to administer sertraline 100 mg; one and one-half tablets once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered on 8/8 or 8/9/23 for a total of two missed doses. A practitioner progress note, dated 7/26/23, read Former Resident #10 had increased anxiety if he missed his sertraline. An admission assessment, dated 8/9/23 for Former Resident #10 read he was independent with ambulation and had a steady gait. The assessment did not indicate Former Resident #10 experienced anxiety or was up throughout the night. Progress notes for August 2023 in the record for Former Resident #10 revealed the following:On 8/9/23, Former Resident #10 was anxious throughout the shift and difficult to redirect. On 8/10/23, Former Resident #10 was difficult to redirect and was up all throughout the night. On 8/11/23 at 6L40 a.m. Former Resident #10 was seated naked on the floor in front of his bed. Onb 811/23 at 8:22 p.m. Former Resident #10 was sent out to the hospital for shaking and back pain. Former Resident #10 came back around 1:00 a.m., "still having tremors. Possible withdrawal from missing meds for (sic) couple of days."A practitioner progress note, dated 8/11/23, read Former Resident #10 was evaluated in the emergency room for tremors of the nervous system. "I discussed this case with (sic) pharmacy, they state that the patient has not been getting his sertraline, he did not receive it ... In light of this I suspect the (Former Resident #10) symptoms are likely secondary to sertraline withdrawal. (Former Resident #10) to be restarted on sertraline ... As discussed above, I suspect that the etiology for the patient's symptoms is withdrawal from sertraline considering the several days that he did not receive it ..."On 9/13/23 at 2:06 p.m., the HSD said the residence had not administered Former Resident #10's medications from 8/8/23 until the evening of 8/10/23. On 9/14/23 at 9:50 a.m., the administrator said the residence had not administered Former Resident #10's medications for two days following his admission to the residence on 8/8/23.b. Polyethylene Glycol A written practitioner's order, dated 7/26/23, directed the residence to administer polyethylene glycol 17 g once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered on 8/9 and 8/10/23.c. MetforminA written practitioner's order, dated 7/26/23, directed the residence to administer metformin 1,000 mg once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered 8/9 and 8/10/23. d. LosartanA written practitioner's order, dated 7/26/23, directed the residence to administer losartan 50 mg once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered on 8/9 and 8/10/23.e. Finasteride A written practitioner's order, dated 7/26/23, directed the residence to administer finasteride 5 mg once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered on 8/8 and 8/9/23.f. AmlodipineA written practitioner's order, dated 7/26/23, directed the residence to administer amlodipine 5 mg once daily. However, the August 2023 MAR for Former Resident #10 read the medication was not administered on 8/8 and 8/9/23. On 9/14/23 at approximately 11:30 a.m., the administrator said she expected the medications to be in the building prior to a resident moving in. She added if there were no orders in the MAR system the resident should not move in. The administrator said she expected the HSD to enter the medications into the MAR system immediately so a resident does not go without being administered their medication.

Plan of correction · submitted by the facility

1520Med/Med Adm-Rprt P/PS/S B▼

Findings

Based on observation, record review and interview, the residence failed to have policies and procedures for documenting, investigating, reporting, and responding to any errors related to accurate accounting of controlled substances and/or medication administration, affecting 29 current residents. (Cross-reference Q1468) Findings include: 1. ObservationOn 9/13/23 at approximately 7:45 a.m., while observing shift change medication count, Staff #9 and the health services director (HSD) found a medication error with a controlled substance. Resident #4 had 20 remaining Haloperidol syringes in the bag. However, the controlled drug record sheet read 22 remaining. She scratched out the number and wrote 20 next to the number. Additionally, she changed the other counts from the previous three entries. 2. Record ReviewOn 9/13/23 at approximately 7:00 a.m., the residence's policy regarding documenting, investigating, reporting, and responding to any errors related to accurate accounting of controlled substances and/or medication administration was requested. On 9/13/23 at 9:15 a.m., the HSD provided the residence's policy binder. However, the binder did not contain any policy regarding documenting, investigating, reporting, and responding to any errors related to accurate accounting of controlled substances and/or medication administration. 3. InterviewsOn 9/13/23 at approximately 7:55 a.m., the HSD stated that she had been recently hired and introduced her own system for documenting medication errors. She added that she was aware the external hospice nurse had administered the medication and the documentation for it should have been handled by the QMAP but had not been completed. Furthermore, during the medication count, the number reported by the QMAP did not align with the actual count of medications on hand. She acknowledged that this constituted a medication error. On 9/14/23 at approximately 11:45 a.m., the administrator said she had been notified of a medication error with Resident #4. She added, the residence policy failed to include the HSD's ability to add or modify orders in the MAR system.

Plan of correction · submitted by the facility

Tag 1520: S/S: B Medication and Medication Administration- Reporting Requirement: Facility shall have P&P for documenting, investigating, reporting, and responding to any errors related to accurate accounting of controlled substances and/or medication administration. Failed to have P&P as per above. On 9/13/23 HSD found a med error with a controlled substance. Resident #4 had 20 remaining Haloperidol syringes in the bag, however, the controlled drug record sheet read 22 remaining. She scratched out the number and wrote 20 next to the number. Additionally, she changed the other counts from the previous three entries. The HSD provided the residence’s policy binder, however, the binder did not contain any policy regarding documenting, investigating, reporting, and responding to any errors related to accurate counting of controlled substances and/or medication administration. Plan of Correction: • Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Resident #9 no longer resides at this facility. The Health Services Director in place at the time of the deficient practice no longer works at the facility.• Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All residents with controlled substances have the potential to be affected. The Health Services Director will audit all controlled substances to ensure all have a correct count.• Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:The Health Services Director and all QMAPs will be educated on the Controlled Substances Count Policy, including the correct procedure if the count is not correct.• Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:The Health Services Director (Registered Nurse) will monitor the narcotic count process twice monthly, alternating shifts, to ensure it is being completed per policy and to ensure the narcotic count is correct for all controlled substances. Any deviations in the count will be investigated, reported to the facility Administrator, and corrective action taken as indicated. Results of the audits will be reported to the facility QAPI meeting monthly for at least three months and longer if indicated.• Include dates when corrective action will be completed:All actions will be completed by 12/24/23.

2976Sec Env-Stff Tr 6 hrS/S B▼

Findings

Based on record review and interview, the residence failed to provide, within 60 days, a minimum of six (6) hours of general training and education on providing care and services for residents with dementia/cognitive impairment with training content provided or recognized by an academic institution, a recognized state or national organization or association, or an independent contractor or group that emphasizes dementia/cognitive impairment care, affecting 29 current residents. (Cross-reference Q810)Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicableb. Chapter VII regulations governing assisted living residences, part 25.15(D), requires that the training shall cover, at a minimum, the following topics:(1) Information on disease processes associated with dementia and cognitive impairment, including progression of the diseases, types and stages of memory loss, family dynamics, behavioral symptoms and limitations to normal activities of daily living;(2) Information on non-pharmacological techniques and approaches used to guide and support residents with dementia/cognitive impairment, wandering, and socially challenging behavioral expressions of need or distress;(3) Information on communication techniques that facilitate supportive and interactive staff-resident relations;(4) Positive therapeutic approaches and activities such as exercise, sensory stimulation, activities of daily living and social, recreation, and rehabilitative activities;(5) Information on recognizing physical symptoms that may cause a change in dementia/cognitive impairment such as dehydration, infection, and swallowing difficulty; along with individualized approaches to assist or address associated symptoms such as pain, decreased appetite and fluid intake, and/or isolation; and(6) Benefits and importance of person-centered care planning and collaborative approaches to delivery of care. 2. Record reviewThe residence's personnel files were reviewed and revealed Staff #3 and #7 were not provided the required six-hour dementia training by the residence. Staff #3 was hired on 12/29/21 and Staff #7 was hired on 9/29/22. On 9/13/23 at 1:30 p.m., the administrator provided dementia-specific related staff training documentation for Staff #7 which revealed Staff #7 had completed five out of six hours of the required training. 3. ObservationOn 9/13/23 and 9/14/23 Staff #3 was observed providing care to residents. On 9/13/23 and 9/14/23 Staff #7 was observed providing care to residents. 4. InterviewsOn 9/14/23 at 12:30 p.m., the administrator stated she was aware of the requirement for staff to have six hours of training and education providing services to residents with dementia and cognitive impairment. The administrator acknowledged that residence did not have the documented and required six-hour general training and education for Staff #3 and #7.

Plan of correction · submitted by the facility

Tag 2976: S/S: B Secure Environment- Staff Training (page 34)Requirement: Within 60 days, the ALR shall provide each staff member a minimum of six hours of general training and education on providing care and services for residents with dementia/cognitive impairment… lists options/requirements on page 34…..Failed to provide training per requirements by an academic institution, a recognized state or national organization or association, or an independent contractor or group that emphasizes dementia/cognitive impairment. Page 35 lists the requirements that must be included in each personnel fileFiles were reviewed for staff #3 (hired 12/29/21) and #7 (hired 9/29/22) and not provided dementia training Plan of Correction: • Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Staff#3. and #7 will recieve the appropriate training for dementia.• Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All active personnel will receive the appropriate dementia training within 60 days. The personnel records will audited by the business office to ensure that all staff are identified who did not receive the dementia training. • Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:During orientation a time will be arranged to schedule training with new staff. The Executive Director will ensure compliance. Upon hire all new staff will be trained within the 60-day time period to ensure proper dementia training has occurred.• Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The results of all staff having received the training will be brought to the monthly QAPI committee for tracking and trending.• Include dates when corrective action will be completed:12-24-23

9999Final ObservationsSurveyor note▼

Findings

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.13.4 The house rules shall list all possible actions which may be taken by the assisted living residence if any rule is knowingly violated by a resident. House rules shall not supersede or contradict any regulation herein, or in any way discourage or hinder a resident's exercise of his or her rights. House rules shall address, at a minimum, the following items:(G) Consumption of alcohol. 14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence ' s Quality Management Program assessment and review. 17.2 Meals shall include a variety of foods, be nutritionally balanced, and sufficient in amount to satisfy resident appetites.(A) Appealing substitutes of similar nutritive value shall be available for residents who choose not to eat food that is initially served or who request an alternative meal.

Plan of correction

The state did not require a plan of correction for this citation.

Reportable Occurrences

37 records

3/29/2026Missing Person · ID 2623K987004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/29/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a missing client. Camera footage revealed client (A), who was an at-risk adult, eloped from the secure environment of the facility via their apartment window by removing the hardware. During the course of the investigation, the healthcare entity conducted a search, contacted police, and conducted interviews. Client (A) had been missing for 45 minutes and was located at a nearby business. Staff returned client (A) to the facility unharmed. The medical provider assessed client (A) with no abnormalities found. The facility provided frequent checks, fixed client (A)'s window, and replaced all hardware on the secure environment's windows. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/19/2026 · released to the public 5/26/2026.

1/8/2026Physical Abuse · ID 2623K987003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/8/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (A) sat on Client (B)’s legs inadvertently and Client (B) used his foot to get Client (A) to move and kicked Client (A) in the eye. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) was found crying. Bruising was observed after the client was sent to Urgent Care, no further treatment necessary. Client (B) stated they did not intend to hurt Client (A), they were getting them to move off of their legs after Client (A) sat on them three times. The piece of furniture was removed to avoid this incident from recurring. The injury to Client (B)’s actions were not reckless or intentional. Staff will continue to redirect Client (A) due to cognitive impairment, and continue to monitor both clients and redirect when necessary. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/27/2026 · released to the public 5/6/2026.

7/25/2025Brain Injury · ID 2523K987008Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/24/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. Staff witnessed Client (A) fall after being pushed by Client (B). During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital. The client (B) was provided with an immediate discharge and Client (A) was provided with additional support from the staff. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/23/2025 · released to the public 9/30/2025.

6/24/2025Sexual Abuse · ID 2523K987007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/24/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. The client was found to have bruising in the anal/vaginal area. During the course of the investigation, the healthcare entity notified law enforcement, sent the client to hospital for evaluation, and conducted interviews. The client denied being harmed by anyone and had multiple falls in the previous week. At the hospital, the client declined an internal exam, but the external exam revealed no tearing or bleeding. The hospital determined the bruising was likely caused by blunt force trauma from multiple falls. The facility ordered adaptive equipment including a hospital bed, bed cane, and fall mat as part of fall prevention strategies. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 11/3/2025 · released to the public 11/10/2025.

6/11/2025Brain Injury · ID 2523K987006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/11/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital. The client’s care plan will be updated to reflect safety interventions should they return to the facility. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 8/27/2025 · released to the public 9/3/2025.

5/22/2025Diverted Drugs · ID 2523K987005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/22/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported diverted drugs. Staff #1 left the facility and did not return. The staff attempted multiple times to contact them. Staff #1 was found in the parking lot in their car, passed out with their car running. They were directed to call someone to pick them up. During the course of the investigation the healthcare entity attempted to locate the missing medication. Staff who counted the narcotics in the cart after, Staff #1 could not be found, identified Morphine and lorazepam were missing for two different clients. Staff #1’s employment was terminated and their access to the facility was disabled. It could not be confirmed Staff #1 took the medication but it is plausible. The event was inconclusive. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 11/16/2025 · released to the public 11/23/2025.

4/30/2025Physical Abuse · ID 2523K987004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/30/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (A) and (B) in a verbal altercation before Client (B) punched Client (A) in the face. Client (A) attempted to defend themselves. No visible injuries to either client. Both clients have cognitive impairment and could not recall the incident. Client (B)’s access to large group gatherings will be limited due to them being triggered and causing negative behaviors. Client (B)’s medications were reviewed for necessary adjustments. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/17/2025 · released to the public 9/24/2025.

2/5/2025Physical Abuse · ID 2523K987003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/5/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. The client alleged staff hit them in the arm and caused bruises. During the course of the investigation, the healthcare entity notified law enforcement, completed an assessment, and conducted interviews. Due to cognitive impairment the client could not provide any further details. The staff denied the allegations. The client had no bruises anywhere on their body. The facility determined the staff resembles a person who harmed the client prior to admission to the facility, acting as a visual trigger. The facility updated the care plan, provided staff education, and made adjustments to the staff members on the care team. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 8/13/2025 · released to the public 8/20/2025.

9/11/2024Diverted Drugs · ID 2423K987019Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/11/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported diverted drugs. During the course of the investigation the healthcare entity attempted to locate the missing medication. One staff member quit during this investigation. The facility implemented a narcotic card count sheet that will be counted every shift and random audits will be conducted. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/26/2025 · released to the public 3/6/2025.

8/7/2024Physical Abuse · ID 2423K987018Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/7/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (B) hit Client (A) in the shoulder after screaming, “move out the way.” Client (B) left the facility with a family member at the time. Staff are working with the hospice provider for Client (B) to ensure their medications are adjusted to help with negative behaviors. Staff will engage and interact with Client (B) to keep behaviors to a minimum. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/25/2025 · released to the public 5/2/2025.

7/24/2024Physical Abuse · ID 2423K987017Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/24/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (B) punch Client (A) in the head while they were seated at a table. Neither client could state what had just happened due to cognitive impairment. Client (B)’s medications were adjusted due to extreme negative behaviors. Staff will also make sure client (B) is not overwhelmed by the noise level. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/25/2025 · released to the public 5/2/2025.

7/22/2024Physical Abuse · ID 2423K987016Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/21/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed both clients in a verbal argument before Client (B) hit Client (A) in the neck with a television remote. Client (A) sustained small scratches that were treated. Client (B) had their medications reviewed to assist with behaviors and was offered another location to watch television. Staff continued to monitor clients. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/10/2025 · released to the public 4/17/2025.

7/7/2024Physical Abuse · ID 2423K987015Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/6/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured clients were separated before the police were notified. Staff witnessed the clients were in a physical altercation with Client (B) instigating the situation. Client (B) punched Client (A) in the stomach, before Client (A) returned the punch. Client (B) was seen at the hospital for their behaviors. Staff continued to monitor the clients and encourage activities to improve behaviors. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/9/2025 · released to the public 4/16/2025.

7/6/2024Brain Injury · ID 2423K987014Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/6/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client’s care plan was updated to reflect safety interventions to include: hospice services, safety checks and the use of a wheelchair. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/4/2025 · released to the public 2/11/2025.

6/6/2024Sexual Abuse · ID 2423K987013Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS: On 6/8/24, the healthcare entity investigated a reportable event of sexual abuse. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 6/19/24, Event ID ZTHT11. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was not submitted within the required timeframe.

Publication

Sent to facility 4/1/2025 · released to the public 4/8/2025.

5/21/2024Physical Abuse · ID 2423K987011Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/21/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (A) punch Client (B) in the face after Client (A) would not leave Client (B)’s room. Staff intervened and no visible injuries were found. Staff implemented monitoring, and educating clients where their rooms are located. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/5/2025 · released to the public 3/12/2025.

3/27/2024Physical Abuse · ID 2423K987009Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 3/27/24 staff witnessed resident (B) push their walker into resident (A) multiple times before pushing resident (A) against the wall. The residents were separated, no visible injuries were seen and staff notified the police. Both residents have cognitive impairment and resident (A) could not recall the incident and resident (B) was unwilling to participate in a conversation. The facility’s investigation concluded the abuse was witnessed by staff. To help prevent a recurrence, the staff were educated to redirect resident (B) when agitated and her medications were reviewed for necessary changes for behaviors. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 12/4/2024 · released to the public 12/11/2024.

3/12/2024Physical Abuse · ID 2423K987008Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 3/12/24, a resident to resident altercation occurred. Resident (A) sustained three skin tears to her forearm. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, the ombudsman, Adult Protective Services and the physician. Resident (A) was provided treatment for her skin tears. The residents in the physical altercation had cognitive impairment and could not recall the incident. The facility investigation concluded an altercation occurred with resident (A) sustaining injuries, however, details of the altercation were unknown. To help prevent a recurrence, staff were educated to keep the residents separated during meal times as this may be the place the altercation took place. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 12/2/2024 · released to the public 12/9/2024.

2/21/2024Misappropriation of Property · ID 2423K987007Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 2/21/24, the facility alleged the person in charge of resident (A)'s finances hasn't paid the facility for multiple months of rent and services and the client is at risk of being discharged from the facility for non-payment. The facility alleged the person in charge financially exploited the resident. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman and Adult Protective Services. The facility tried to reach the person in charge of resident (A) 's finances multiple times without any results regarding payment for services. The resident was issued a 30-day involuntary discharge notice for non-payment. The facility investigation concluded they can not prove financial exploitation but the resident's bill remained unpaid. The facility planned to assist resident (A) safely move into a skilled nursing facility. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/19/2024 · released to the public 11/26/2024.

2/10/2024Physical Abuse · ID 2423K987005Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 2/11/24, resident (A) was found to have injuries of an unknown source. Resident (A) had a skin tear and bruising to their bilateral upper extremities. Resident (A) was sent to the hospital for further evaluation. Resident (A) stated he had been beat up by two staff members (1) and (2) the evening prior. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, the ombudsman, Adult Protective Services and the physician. According to interviews, resident (A) was seated in resident (B)'s room when he was removed from the room against both their wishes. Both residents stated the same account of what had occurred. The bruises appeared to be handprints to resident (A)’s forearms. Resident (A) was admitted to the hospital for other non-related concerns. No new concerns with other residents who were interviewed. The facility investigation concluded resident (A)’s rights were violated and physical abuse was substantiated. To help prevent a recurrence, both staff member's employment was terminated. Dementia and sexuality training was provided to the staff. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/26/2024 · released to the public 12/3/2024.

1/19/2024Physical Abuse · ID 2423K987003Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/17/24, a female resident (A) in her 80s complained of increased pain in her right knee prior to going out for an appointment. Resident (A) refused medication and accepted her heating pad when she returned. She had a history of knee pain. On 1/19/24, resident (A) had lethargy, hip and back pain and was sent out to the hospital for an evaluation and was diagnosed with a right hip fracture. The cause was unknown. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family, third party agency and physician. Resident (A) was considered independent with walking and completed her own care. Staff indicated they were unaware of anything that could cause resident (A) to suffer a fracture. Resident (A) returned to the facility on 1/24/24 and stated she did not have a fall. She didn't know the cause of her fracture. Resident (A) was diagnosed with dementia but was still very adamant about being independent. The facility investigation concluded it was probable resident (A) experienced an unwitnessed fall, got herself up, and did not notify staff due to being forgetful. No abuse was substantiated. To help prevent a recurrence resident (A)’s plan of care was updated to reflect her current needs with walking and additional support. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/25/2024 · released to the public 12/2/2024.

1/12/2024Physical Abuse · ID 2423K987002Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/12/24, a qualified medication administration person (QMAP) overheard a male resident (A) in his 70s yelling when saw female resident (B) in her 80s with blood on her nose and mouth. The residents admitted to hitting each other. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, Adult Protective Services and physician. The residents were separated. Resident (B)’s nose was bleeding. Resident (A) had no injuries. The facility determined resident (B) attempted to take resident (A)’s cane when he hit her. Resident (A) stated he was defending himself when hit resident (B). Resident (B) did not recall the event. The facility investigation concluded the allegation was substantiated. To help prevent a recurrence, staff would continue to monitor the residents and intervene when any resident appeared upset. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/25/2024 · released to the public 12/2/2024.

12/18/2023Sexual Abuse · ID 2323K987022Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 12/19/23, a female resident (A) in her 80s alleged she may have been raped but was not sure by a male resident (B) in his 90s. Resident (A) expressed discomfort with resident (B) the day after they were discovered having an intimate relationship. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. Resident (A) was assessed without any external findings of sexual trauma. The residents were separated into different units of the facility. Resident (A) could not recall the event afterwards. Resident (B) described being intimate with a female but there was no intercourse. Staff that found the residents wrote statements that the interaction appeared mutual between both residents until resident (A) reported something different the next day. Staff said Resident (A) initially invited resident (B) into her room. Per the facility, they reported the police indicated no crime had been committed. The facility investigation concluded the act was mutual at the time as resident (A) invited resident (B) into her room. No abuse was substantiated. To help prevent a recurrence, they have been separated into different units. One resident can not access the other. Resident (B) only comes out of his room for meals and to watch television and staff will monitor him in those areas. Resident (A) will be provided with additional psychological support. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/15/2024 · released to the public 11/27/2024.

12/3/2023Physical Abuse · ID 2323K987021Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 12/3/23, qualified medication administration person (QMAP) (1) found two female residents in an physical altercation. Resident (B) in her 80s had a hold of resident (A) in her 70s hair. Resident (A) scratched resident (B)’s arms creating skin tears before staff could separate the residents. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and Adult Protective Services. Resident (B) was provided treatment for her skin tears and increased supervision. Both residents have cognitive impairment and did not remember the incident. The facility investigation concluded the initial altercation was not witnessed but determined resident (B) was most likely the aggressor. Physical abuse was substantiated. To help prevent a recurrence, resident (B) had increased monitoring until she was moved to another unit. Staff will continue to monitor her for behaviors. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/7/2024 · released to the public 11/14/2024.

11/28/2023Physical Abuse · ID 2323K987020Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 11/29/23, a female resident (A) in her 60s stated during care staff member (1) threw a brief at her and hit her in the head. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, physician and Adult protective services. Resident (A) was assessed without visible injuries. Staff member (1) was suspended pending the investigation. Staff member (1) denied the allegation and stated resident (A) did not like them. No other residents had any issues with staff member (1). No one witnessed the allegation. The facility investigation concluded there was not enough evidence to state abuse occurred. To help prevent a recurrence, staff member (1) was able to return to work and will not be assigned to assist resident (A). Staff will monitor resident (A) for safety and any psychosocial changes. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

10/24/2023Neglect · ID 2323K987019Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 10/2/23, reportedly, staff members failed to follow the facility policy for falls and post-fall documentation. Resident (A) was found on the floor by staff after complaining of pain, was lifted off the floor, taken to the bathroom and placed back in her chair without an assessment. Staff failed to notify the family, physician or management and allegedly failed to keep resident (A) safe post fall. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, Adult Protective Services, management and physician. The family of resident (A), once notified late, decided to send resident (A) to the hospital where resident (A) was diagnosed with a fracture of her neck. Resident (A) could not recall what happened. Staff member (1) was suspended pending the investigation. Staff member acknowledged resident (A) complained of pain, but did not share this information with staff member (2). Staff member (1) reported the fall to oncoming staff on the 6:00 a.m. -2:00 p.m. but failed to follow the fall policy. The facility investigation concluded the incident was substantiated and the staff were neglectful. To help prevent a recurrence, staff member (1)’s employment was terminated and staff member (2) was given a final warning. Staff will assist resident (A) with her needs and monitor her neck brace. On going training will be done with staff on fall management to ensure resident safety. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 10/2/2024 · released to the public 10/3/2024.

9/27/2023Physical Abuse · ID 2323K987017Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 9/27/23, a female resident (A) in her 80s was identified to have a skin tear to her arm alleging that she was attacked by another female resident (B) in her 80s who pushed her and tried to take her walker. Resident (A) also reported being kicked and grabbed in the back by resident (B) later in the investigation. Resident (A) sustained multiple injuries. There were no witnesses to the allegation. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. The residents were kept separate. Resident (A) was provided treatment for her injuries. Resident (A) sustained a small skin tear to her left forearm and right finger. Resident (B) could not recall the incident due to cognitive impairment. The facility investigation concluded it appeared as resident (A) was physically abused by resident (B). To help prevent a recurrence, resident (B) will be monitored by staff for any further behaviors. Resident (A) agreed to move to another part of the facility and staff kept the residents separated. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 8/30/2024 · released to the public 9/6/2024.

7/23/2023Physical Abuse · ID 2323K987013Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 7/23/23, a facility staff member (staff 1) and an agency staff member (staff 2) got into a physical altercation in front of residents. At one point, staff (1) pushed or body checked staff (2) causing them to fall into two residents sitting nearby. There were reported injuries to both residents and resident (B) started crying and appeared scared. A third resident (C) attempted to pull the employees part and did not suffer an injury. Once staff (2) got away, they called 911 and emergency services responded. Staff (3) redirected staff (1) to a back area away from residents. All witnesses reported staff (1) instigated the fight. The police arrested staff (1) for alleged reckless endangerment and 3rd degree assault and removed them from the facility. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, ombudsman, Adult Protective Services, and physician. Resident (A) was transported to the hospital for an evaluation of bilateral skin tears; the right forearm was reported to be large. First aid treatment was provided, and he returned. Staff said resident (B) was holding her knee and crying. She complained of pain and staff observed swelling. Staff notified the physician regarding the medical complaint. Ice was provided and staff provided emotional support. Resident (B) remained upset for a few days and then returned to her baseline. All residents involved were being monitored for changes in routine, demeanor, and mood. Other staff reported staff (1) had been upset and angry that morning and was offered a solution to leave due to feeling upset with staff. Staff (1) left and then returned to the building on his own accord when he started the fight. From the facility’s investigation, management concluded staff (1)’s actions were reckless causing injuries to staff (2) and other residents. Staff (1)’s employment was terminated. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary was based on information provided by the agency/facility to the Occurrence Section of the Department and reported to be accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, a representative from the State agency would review the facility/agency’s occurrence reporting history. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the State Agency.

Publication

Sent to facility 4/29/2024 · released to the public 5/3/2024.

6/21/2023Physical Abuse · ID 2323K987011Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 6/21/23 at approximately 11:45 p.m., a staff member (staff 1) heard someone yelling “help me!” Upon responding, staff (1) observed resident (B), in his 70s, hitting another resident (A), in his 90s, repeatedly while resident (A) was on the floor. Staff (1) tried to intervene and get resident (B) to stop and that was when staff (1) was also struck in their right jaw by resident (B). Staff (1) ran to call 911 as resident (B) continued to strike resident (A) with a metal object. Staff (1) then went back to the room and begged resident (B) to stop hitting resident (A). Resident (B) was yelling, "where is his son?” Resident (B) struck resident (A) with the metal object. The 911 operator told staff (1) to leave the room. A few minutes later resident (B) came out of the room and charged towards staff (1) with the metal object in his hand still yelling. Staff (1) was able to run into an office and shut the door. The police arrived. Resident (B) was escorted off the property and taken to jail. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, ombudsman, Adult Protective Services and physician. As the police were on site and the situation was safe, the paramedics arrived and evaluated resident (A) and transferred him to the hospital. Resident (A) was admitted to the hospital with broken ribs, a possible broken arm or wrist and lacerations to his head. Resident (A)'s family stated resident (A) told them he was confused where his room was located and had asked a female resident for directions. He then remembered being beat up and did not know why resident (B) did that. The facility investigation concluded resident (B) assaulted resident (A) causing injuries. The reason was unknown. The facility issued an immediate discharge notice to resident (B), and he did not return. Management modified the environment to help resident (A) identify his room. Staff conducted hourly rounds to assist resident (A) with his transition to this location and staff continued monitoring resident (A)'s care needs. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and reported to be accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the State Agency.

Publication

Sent to facility 4/11/2024 · released to the public 4/18/2024.

5/27/2023Physical Abuse · ID 2323K987009Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 5/27/23, as staff (1) stood with resident (B) in the hallway, resident (A) wandered by them. Resident (B) reached out and slapped resident (A) on the face. Resident (A) then slapped resident (B) on the face before staff could intervene. Both residents were in their 70s. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, and physician. Both residents were separated immediately. No visible injuries were observed on either resident, and due to their cognitive impairments, they were unable to participate in a follow up interview. Staff reported resident (B) has been exhibiting signs of agitation at times, but this behavior came out of nowhere. She had recently been diagnosed with a urinary tract infection, which could have been contributing to an increase in her aggressive behaviors. Staff thought resident (A) just reacted to being slapped. The facility concluded resident (B)'s physical aggression and impulsiveness was related to the infection and that she was not targeting resident (A) specifically. Resident (B) received antibiotics to treat the infection. In addition, staff continued monitoring resident (B) to help anticipate her needs and redirect her away from others as needed. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 2/26/2024 · released to the public 3/4/2024.

5/10/2023Physical Abuse · ID 2323K987008Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 5/10/23, a staff member assisted resident (B) to her room while resident (A) followed close behind. As they got to resident (B)'s door, staff redirected resident (A) to leave the area. In response, resident (A) got agitated and grabbed resident (B)'s face. Staff intervened and separated the residents, who were in their 70s. Initially, staff observed a small scratch on resident (B)'s face. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, Adult Protective Services and physicians. Resident (A) was redirected away from resident (B). The nurse confirmed the presence of a facial scratch and later, a bruise appeared on resident (B)'s upper lip. First aid treatment was provided. Both residents had cognitive impairments and could not recall the event. Staff reported it could be challenging to redirect resident (A) from doorways, but she typically responded to gentle redirection. However, the facility reported this was the first physical encounter with another resident when being redirected. From the findings, the facility concluded resident (A) was not specifically targeting resident (B), but she reacted in an aggressive manner when staff attempted to redirect her away from following resident (B) into the room. Resident (A)'s behavioral plan was updated to reflect the potential for agitation and anger. Staff continued monitoring the residents to help redirect them in a calm and gentle manner. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 2/13/2024 · released to the public 2/20/2024.

5/4/2023Physical Abuse · ID 2323K987007Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 5/4/23, a staff member (1) reported resident (A) was eating at a table when another resident (B) went up to her and said “hey that is my spoon." Resident (B) then attempted to take the spoon from resident (A), and in response, resident (B) hit and smacked resident (A) on the face causing redness to the area. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, and physician. The residents were separated from each other. Both residents have cognitive impairment and could not recall what had just happened. The facility investigation concluded the incident happened with resident (B) getting upset and hitting resident (A) on the face. To help prevent a recurrence, staff monitoring remained in place and staff redirected resident (B) if they saw her heading towards other peers' items or belongings. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 2/12/2024 · released to the public 2/12/2024.

3/16/2023Physical Abuse · ID 2323K987006Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 03/16/23 female resident (A), in her 80s, hit male resident (B) on his arm. Resident (B) was in his 70s. Both residents had significant cognitive impairment. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians. The residents were separated. Resident (B) was assessed and had no visible injuries. Neither resident could remember the incident due to their cognitive status. Lab work was ordered for resident (A) and it was determined she had a urinary tract infection and treatment orders were received. The residents were kept separated. Staff were to re-introduce them to each other during activities to provide a positive environment and rebuild trust between them. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/6/2023 · released to the public 11/13/2023.

2/27/2023Physical Abuse · ID 2323K987004Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 2/27/23 a male resident (B) in his 60s reported that he had pushed another male resident (A) in his 90s down to the ground. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. Resident (A) was assisted off the ground by two staff members (1) and (2) after hearing yelling. No visible injuries were seen. Resident (B) immediately self reported the incident and stated that resident (A) had made him mad and had gotten in his face. Resident (A) did not recall what happened. Both residents have cognitive impairment. Resident (B) was taken to his room to calm down. The facility investigation concluded it was difficult to understand what triggered resident (B) to push resident (A). To help prevent a recurrence staff increased monitoring of both residents, staff will also redirect residents and calm resident (B) down with redirection. The facility will continue to evaluate the appropriateness of resident (B) to remain living in the facility with behaviors. This event is linked with a separate occurrence event #2323K987003. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 8/14/2023 · released to the public 8/20/2023.

2/27/2023Physical Abuse · ID 2323K987005Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 2/27/23 as witnessed by resident aide (1) a male resident (B) in his 70s went up to the table a female resident (A) in her 80s was seated at. Resident (B) tried to take resident (A)’s food, resident (A) put her hand up and resident (B) grabbed her hand/arm and caused a bruise to her right forearm. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, and families/guardians. The residents were separated. A dime size bruise was seen on resident (A) right forearm. Resident (A) was upset immediately afterwards however returned to baseline and had difficulty communicating what occurred. Resident (B) could not answer questions. Both residents have cognitive impairment. Staff indicated that resident (B) may have been hungry reaching for resident (A) food. The facility investigation concluded resident (A) was waving resident (B) away from her food when he grabbed her arm which left a bruise. To help prevent a recurrence staff will intervene sooner, and provide resident (B) with larger portions of food to prevent him from trying to eat other residents' food. Staff will monitor resident (B) during meal times and offer seconds. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 8/14/2023 · released to the public 8/20/2023.

2/11/2023Physical Abuse · ID 2323K987003Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 2/11/23 a male resident (A) in his 60s entered into another male resident (B)s apartment. Resident (B) shoved resident (A) to get out of his apartment and yelling was heard by staff member (1). When staff member (1) arrived in the area, they saw resident (B) with his hands on resident (A)’s neck and arm. Resident (A) sustained injuries. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, and families/guardians. The residents were separated and resident (B) was redirected to get him to calm down. Resident (A) was assessed and bruising was seen to his right bicep and a scratch on his neck. The areas were provided treatment. Resident (A) did not recall the event and has cognitive impairment. Resident (B) was in a good mood during the interview, as the description was based on his interview as no staff had witnessed the altercation. The facility investigation concluded based on the admission of resident (B), he was trying to get resident (A) out of his room and caused injuries. To help prevent a recurrence both residents would be monitored. Interventions were put into place to redirect and de-escalate any aggressive behavior. Resident (A) was offered a day program in an alternate community that is lower stimulation. Resident (B) was encouraged to lock his apartment door, and staff will remove him for a situation when he became agitated. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 8/14/2023 · released to the public 8/20/2023.

2/5/2023Physical Abuse · ID 2323K987002Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 2/5/23 as witnessed by qualified medication administration person (QMAP) (1) a male resident (B) in his 70s accidentally bumped into a female resident (A) in her 80s while she was seated in her wheelchair. Resident (A) proceeded to hit resident (B) in the back of his neck and resident (B) then hit resident (A) in her face near her eye/cheek area. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and hospice. Both residents were separated and redirected. Both were assessed and resident (A) was found to have a bloodshot eye and a small cut by her eye/cheek area. Neither resident could recall what happened due to cognitive impairment. No other residents reported any negative concerns. No other staff indicated that resident (A) and (B) had been in any previous altercations. The facility investigation concluded the initial action from resident (B) was an accident. Resident (A)’s response and resident (B)’s follow up response of hitting each other caused resident (A) to sustain an injury. To help prevent a recurrence the facility staff will monitor both residents and keep them out of each other's personal space and to wander in a safe environment if they want to move freely. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 9/5/2023 · released to the public 9/12/2023.